Care Wisconsin 2017 Formulary Addendum

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1 - Non-Formulary, PA - Prior Authorization, HR High Risk Medication, QL Quantity Limit per 30 days, EFFECTIVE 01/01/ ABILIFY MAINT INJ 400 1/26 + ST2 Formulary Enhancement N/A ABILIFY MAINT SUSP 300 1/26 + ST2 Formulary Enhancement N/A IM* (1.5ML SYR) ADRUCIL INJ 500/10ML 1 + BvD Formulary Enhancement N/A AMP-SULBACTA INJ 1.5GM 1 + BvD Formulary Enhancement N/A ARIPIPRAZOLE TAB 15 1 Formulary Enhancement N/A ODT BUPROPION TAB /31 Formulary Enhancement N/A CAZIANT PAK 1 Formulary Enhancement N/A CHOLESTYRAMINE LIGHT 1 Formulary Enhancement N/A POW 4 GM/DOSE COMPRO SUP 25 1 Formulary Enhancement N/A EMEND SUS BvD Formulary Enhancement N/A EPITOL TAB Formulary Enhancement N/A ERAXIS INJ PA1 Formulary Enhancement N/A GENGRAF CAP BvD Formulary Enhancement N/A HUMIRA PEN INJ PSORIASI 1 Formulary Enhancement N/A LAMOTRIGINE TAB 25 ODT 1 Formulary Enhancement N/A LAMOTRIGINE TAB 50 ER 1 Formulary Enhancement N/A LAMOTRIGINE TAB 50 ODT 1 Formulary Enhancement N/A LAMOTRIGINE TAB DISP Formulary Enhancement N/A LAMOTRIGINE TAB DISP Formulary Enhancement N/A LARISSIA TAB 1 Formulary Enhancement N/A MESALAMINE TAB 800 DR 1 Formulary Enhancement N/A Page 1 of 12

2 Care Wisconsin - Non-Formulary, PA - Prior Authorization, HR High Risk Medication, QL Quantity Limit per 30 days, METHOCARBAM INJ 100/ML 1 + HR Formulary Enhancement N/A NILUTAMIDE TAB /31 Formulary Enhancement N/A NORGESTIM-ETH ESTRAD TRIPHASIC TAB 0.18/0.215/ MCG 1 Formulary Enhancement N/A ORENCIA CLCK INJ 125/ML 1 + ST2 Formulary Enhancement N/A PRAMIPEXOLE TAB /31 Formulary Enhancement N/A PREDNISONE TAB 10 (21) 1 Formulary Enhancement N/A PREDNISONE TAB 10 (48) 1 Formulary Enhancement N/A PREDNISONE TAB 5 (21) 1 Formulary Enhancement N/A PREDNISONE TAB 5 (48) 1 Formulary Enhancement N/A RELISTOR TAB ST2 Formulary Enhancement N/A REPATHA PUSH INJ 420/ PA1 Formulary Enhancement N/A SPS SUS 15GM/60 1 Formulary Enhancement N/A SUMATRIPTAN SUC SOL 5/31 Formulary Enhancement N/A AUTO-INJ 4 /0.5ML SUBQ VIIBRYD KIT STARTER 1/26 Formulary Enhancement N/A VINCASAR PFS INJ 1/ML 1 + BvD Formulary Enhancement N/A YONDELIS INJ PA2 Formulary Enhancement N/A EFFECTIVE 03/01/ 8-MOP CAP 10 1 CMS Required Deletion N/A ABACA/LAMIVU TAB Formulary Enhancement N/A ADRIAMYCIN INJ BvD Formulary Enhancement N/A ALYACEN TAB 1/35 1 Formulary Enhancement N/A AMLOD/OLMESA TAB AMLOD/OLMESA TAB Formulary Enhancement N/A Formulary Enhancement N/A Page 2 of 12

3 - Non-Formulary, PA - Prior Authorization, HR High Risk Medication, QL Quantity Limit per 30 days, AMLOD/OLMESA TAB 5-20 Formulary Enhancement N/A AMLOD/OLMESA TAB 5-40 Formulary Enhancement N/A APREPITANT CAP BvD Formulary Enhancement N/A APREPITANT CAP 40 + BvD Formulary Enhancement N/A APREPITANT CAP 80 + BvD Formulary Enhancement N/A APREPITANT PAK 80 & /31 + BvD Formulary Enhancement N/A AZITHROMYCIN TAB 500 (3 PACK) 1 Formulary Enhancement N/A BUPROBAN TAB /31 CMS Required Deletion N/A CERVARIX INJ 1 CMS Required Deletion N/A DAPTOMYCIN INJ BvD Formulary Enhancement N/A EPCLUSA TAB PA1 Formulary Enhancement N/A EPINEPHRINE SOL AUTO-INJ 1 Formulary Enhancement N/A 0.15 /0.3ML INJ EPIRUBICIN INJ BvD Formulary Enhancement N/A ERGOMAR SUB 2 1 CMS Required Deletion N/A ERYTHROM ETH SUS 200/5ML 1 Formulary Enhancement N/A ETHYNODIOL TAB Formulary Enhancement N/A FEMYNOR TAB Formulary Enhancement N/A GILDESS TAB 1.5/30 1 CMS Required Deletion N/A INVOKAMET XR TAB /31 Formulary Enhancement N/A 1000 INVOKAMET XR TAB /31 Formulary Enhancement N/A INVOKAMET XR TAB /31 Formulary Enhancement N/A Page 3 of 12

4 Care Wisconsin - Non-Formulary, PA - Prior Authorization, HR High Risk Medication, QL Quantity Limit per 30 days, INVOKAMET XR TAB /31 Formulary Enhancement N/A KINRIX INJ 1 Formulary Enhancement N/A KYPROLIS SOL BvD Formulary Enhancement N/A KYPROLIS SOL BvD Formulary Enhancement N/A LARTRUVO INJ 10/ML 1 + PA2 Formulary Enhancement N/A LORCET HD TAB /31 Formulary Enhancement N/A LOW-OGESTREL TAB 1 Formulary Enhancement N/A MELOXICAM SUS 7.5/5ML 310/31 CMS Required Deletion N/A MENEST TAB PA2 CMS Required Deletion N/A METHOTREXATE INJ 25/ML 1 + BvD Formulary Enhancement N/A METHYLERGON TAB CMS Required Deletion N/A MYCOPHENOLAT INJ BvD Formulary Enhancement N/A MYTESI TAB Formulary Enhancement N/A NAPHAZOLINE SOL 0.1% OP 1 CMS Required Deletion N/A NIFEDICAL XL TAB 30 NIFEDICAL XL TAB 60 62/31 62/31 CMS Required Deletion N/A CMS Required Deletion N/A NIFEDIPINE ER OSMOTIC RELEASE TAB ER 24H 30 62/31 Formulary Enhancement N/A NIFEDIPINE ER OSMOTIC RELEASE TAB ER 24H 60 62/31 Formulary Enhancement N/A NIFEDIPINE ER OSMOTIC RELEASE TAB ER 24H 90 62/31 Formulary Enhancement N/A NITROGLYCERI SUB Formulary Enhancement N/A NITROGLYCERN SUB Formulary Enhancement N/A NITROGLYCERN SUB Formulary Enhancement N/A Page 4 of 12

5 Care Wisconsin - Non-Formulary, PA - Prior Authorization, HR High Risk Medication, QL Quantity Limit per 30 days, Formulary Enhancement N/A Formulary Enhancement N/A NORETH/ETHIN TAB 1/20 1 Formulary Enhancement N/A OFLOXACIN TAB Formulary Enhancement N/A OLM MED/HCTZ TAB Formulary Enhancement N/A OLM MED/HCTZ TAB Formulary Enhancement N/A OLM MED/HCTZ TAB OLMESA MEDOX TAB 20 Formulary Enhancement N/A OLMESA MEDOX TAB 40 Formulary Enhancement N/A OLMESA MEDOX TAB 5 Formulary Enhancement N/A OLMESARTAN-AMLODIPINE- HCTZ TAB OLMESARTAN-AMLODIPINE- HCTZ TAB Formulary Enhancement N/A OLMESARTAN-AMLODIPINE- HCTZ TAB Formulary Enhancement N/A OLMESARTAN-AMLODIPINE- HCTZ TAB Formulary Enhancement N/A OLMESARTAN-AMLODIPINE- HCTZ TAB Formulary Enhancement N/A ORKAMBI TAB PA1 Formulary Enhancement N/A OSELTAMIVIR CAP /365 Formulary Enhancement N/A OSELTAMIVIR CAP 45 56/365 Formulary Enhancement N/A OSELTAMIVIR CAP 75 56/365 Formulary Enhancement N/A PANCREAZE CAP 1 Formulary Enhancement N/A PEDIARIX INJ 0.5ML 1 Formulary Enhancement N/A PERTZYE CAP DR 4000 U 1 Formulary Enhancement N/A QUETIAPINE TAB 150 ER 93/31 Formulary Enhancement N/A QUETIAPINE TAB 200 ER Formulary Enhancement N/A QUETIAPINE TAB 300 ER 62/31 Formulary Enhancement N/A QUETIAPINE TAB 400 ER 62/31 Formulary Enhancement N/A Page 5 of 12

6 Care Wisconsin - Non-Formulary, PA - Prior Authorization, HR High Risk Medication, QL Quantity Limit per 30 days, QUETIAPINE TAB 50 ER 124/31 Formulary Enhancement N/A RANITIDINE INJ 50/2ML 1 CMS Required Deletion N/A RASAGILINE TAB 0.5 Formulary Enhancement N/A RASAGILINE TAB 1 Formulary Enhancement N/A RESERPINE TAB PA1 CMS Required Deletion N/A RESERPINE TAB CMS Required Deletion N/A STAVUDINE SOL 1/ML 2480/31 CMS Required Deletion N/A TRAVOPROST DRO 0.004% 1 CMS Required Deletion N/A TYZEKA TAB PA1 CMS Required Deletion N/A VALGANCICLOV SOL 50/ML 1 Formulary Enhancement N/A VARIZIG INJ 125UNIT 1 CMS Required Deletion N/A VITEKTA TAB CMS Required Deletion N/A VITEKTA TAB 85 1 CMS Required Deletion N/A YUVAFEM TAB 10MCG 1 Formulary Enhancement N/A ZERIT SOL 1/ML 2480/31 Formulary Enhancement N/A EFFECTIVE 04/01/ AMIFOSTINE SOL 500 IV 1 CMS Required Deletion N/A AMIODARONE HCL TAB 100 DOXYCYCLINE HYC SOL 100 IV LOPINAVIR-RITONAVIR SOL /5ML MENOMUNE INJECTABLE SUBQ NECON 1/35 (28) TAB MCG 1 Formulary Enhancement N/A 1 CMS Required Deletion N/A 1 Formulary Enhancement N/A 1 CMS Required Deletion N/A 1 CMS Required Deletion N/A Page 6 of 12

7 - Non-Formulary, PA - Prior Authorization, HR High Risk Medication, QL Quantity Limit per 30 days, 1 Formulary Enhancement N/A 93/90 + HR 93/31 + HR Formulary Enhancement N/A 1 + PA1 CMS Required Deletion N/A 1 Formulary Enhancement N/A /2ML INJ RUBRACA TAB PA2 Formulary Enhancement N/A RUBRACA TAB PA2 Formulary Enhancement N/A EFFECTIVE 06/01/ AMETHYST TAB MCG 1 CMS required Deletion N/A AZILECT TAB 0.5 AZILECT TAB 1 AZOR TAB AZOR TAB rasagiline mes tab 0.5 mg, 1 + ql rasagiline mes tab 1 mg, 1 + ql NORGESTIMATE-ETH ESTRADIOL TAB MCG PHENOBARBITAL TAB 32.4 PRALUENT SOL PFS 150 /ML SUBQ RANITIDINE HCL SOL 50 amlodipineolmesartan tab mg, 1 + ql amlodipineolmesartan tab mg, 1 + ql Page 7 of 12

8 - Non-Formulary, PA - Prior Authorization, HR High Risk Medication, QL Quantity Limit per 30 days, AZOR TAB 5-20 AZOR TAB 5-40 CALCIUM ACETATE TAB 667 amlodipineolmesartan tab 5-20 mg, 1 + ql amlodipineolmesartan tab 5-40 mg, 1 + ql 1 Formulary Enhancement N/A CELLCEPT IV SOL 500 IV 1 + BvD CUBICIN SOL 500 IV 1 + BvD DESVENLAFAXINE SUCC ER TAB 24HR 100 DESVENLAFAXINE SUCC ER TAB 24HR 25 DESVENLAFAXINE SUCC ER TAB 24HR 50 E.E.S. GRANULES SUSP 200 /5ML EMEND CAP 125 mycophenolate mofetil hcl sol 500 mg iv, 1 + bvd daptomycin sol 500 mg iv, 1 + bvd 1 Formulary Enhancement N/A 1 Formulary Enhancement N/A 1 Formulary Enhancement N/A 1 + BvD erythromycin ethylsuc susp 200 mg/5ml, 1 aprepitant cap 125 mg, 1 + ql + bvd Page 8 of 12

9 - Non-Formulary, PA - Prior Authorization, HR High Risk Medication, QL Quantity Limit per 30 days, EMEND CAP 40 EMEND CAP 80 & 125 EMEND CAP 80 EPINEPHRINE SOL AUTO-INJ 0.3 /0.3ML INJ EPZICOM TAB ERYPED 200 SUSP 200 /5ML GALANTAMINE HBR TAB 12 GALANTAMINE HBR TAB 4 GALANTAMINE HBR TAB 8 KALETRA SOL /5ML KISQALI 200 DOSE TAB BvD 12/31 + BvD + BvD aprepitant cap 40 mg, 1 + ql + bvd aprepitant cap 80 & 125 mg, 1 + ql 12/31 + bvd aprepitant cap 80 mg, 1 + ql + bvd 2/60 Formulary Enhancement N/A 1 abacavir sullamivudine tab mg, 1 + ql erythromycin ethylsuc susp 200 mg/5ml, 1 1 Formulary Enhancement N/A 1 Formulary Enhancement N/A 1 Formulary Enhancement N/A 1 lopinavirritonavir sol mg/5ml, PA2 Formulary Enhancement N/A Page 9 of 12

10 Care Wisconsin - Non-Formulary, PA - Prior Authorization, HR High Risk Medication, QL Quantity Limit per 30 days, KISQALI 400 DOSE TAB PA2 Formulary Enhancement N/A KISQALI 600 DOSE TAB PA2 Formulary Enhancement N/A KLOR-CON M10 TAB ER 10 MEQ 1 Formulary Enhancement N/A KLOR-CON M20 TAB ER 20 MEQ 1 Formulary Enhancement N/A LINZESS CAP 72 MCG 1 Formulary Enhancement N/A MENOMUNE INJ SUBQ 1 Formulary Enhancement N/A METFORMIN HCL ER (OSM) TAB ER 24H /31 CMS required Deletion N/A NILANDRON TAB 150 NITROFURANTOIN MONOHYD MACRO CAP 100 NITROSTAT TAB SL 0.3 SL NITROSTAT TAB SL 0.4 SL NITROSTAT TAB SL 0.6 SL OXACILLIN SOD SOL 2 GM INJ POTASSIUM CHLORIDE CRYS ER TAB 10 MEQ POTASSIUM CHLORIDE CRYS ER TAB 20 MEQ 62/31 nilutamide tab 150 mg, 1 + ql 62/ HR Formulary Enhancement N/A nitroglycerin tab sl 0.3 mg sl, 1 nitroglycerin tab sl 0.4 mg sl, 1 nitroglycerin tab sl 0.6 mg sl, 1 1 CMS required Deletion N/A 1 Formulary Enhancement N/A 1 Formulary Enhancement N/A Page 10 of 12

11 - Non-Formulary, PA - Prior Authorization, HR High Risk Medication, QL Quantity Limit per 30 days, PRADAXA CAP Formulary Enhancement N/A PRALUENT SOL PFS 75 /ML SUBQ 1 + PA1 CMS required Deletion N/A RIVASTIGMINE PAT 24H 13.3 /24HR TD Formulary Enhancement N/A RIVASTIGMINE PAT 24H 4.6 /24HR TD Formulary Enhancement N/A RIVASTIGMINE PAT 24H 9.5 /24HR TD Formulary Enhancement N/A SELZENTRY TAB /31 Formulary Enhancement N/A SELZENTRY TAB 75 62/31 Formulary Enhancement N/A SEROQUEL XR TAB ER 24H 150 SEROQUEL XR TAB ER 24H 200 SEROQUEL XR TAB ER 24H 300 SEROQUEL XR TAB ER 24H 400 SEROQUEL XR TAB ER 24H 50 TAMIFLU CAP 30 93/31 62/31 62/31 124/31 + ST2 112/365 quetiapine fum er tab er 24h 150 mg, 1 + ql 93/31 quetiapine fum er tab er 24h 200 mg, 1 + ql quetiapine fum er tab er 24h 300 mg, 1 + ql 62/31 quetiapine fum er tab er 24h 400 mg, 1 + ql 62/31 quetiapine fum er tab er 24h 50 mg, 1 + ql 124/31 oseltamivir phos cap 30 mg, 1 + ql 112/365 Page 11 of 12

12 - Non-Formulary, PA - Prior Authorization, HR High Risk Medication, QL Quantity Limit per 30 days, TAMIFLU CAP 45 TAMIFLU CAP 75 TRIBENZOR TAB TRIBENZOR TAB TRIBENZOR TAB TRIBENZOR TAB TRIBENZOR TAB /365 56/365 VALCYTE SOL 50 /ML 1 oseltamivir phos cap 45 mg, 1 + ql 56/365 oseltamivir phos cap 75 mg, 1 + ql 56/365 olmesartanamlodipine-hctz tab mg, 1 + ql olmesartanamlodipine-hctz tab mg, 1 + ql olmesartanamlodipine-hctz tab mg, 1 + ql olmesartanamlodipine-hctz tab mg, 1 + ql olmesartanamlodipine-hctz tab mg, 1 + ql valganciclovir hcl sol 50 mg/ml, 1 Page 12 of 12

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