Care Wisconsin 2018 Formulary Addendum

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1 pharmacies, - Non-Formulary, PA - Prior Authorization, QL Quantity Limit per 30 days, ST - Step Therapy EFFECTIVE 01/01/ 0.5 ML SUMATRIPTAN 4 MG CARTRIDGE 0.5 ML SUMATRIPTAN 6 MG Last Updated: 03/24/ Effective date: 04/01/ 5/31 5/31 CARTRIDGE AMNESTEEM CAP 10MG AMNESTEEM CAP 20MG AMNESTEEM CAP 40MG Benlysta SOL Auto-injector 200 MG/ML SUBQ Benlysta SOL PFS 200 MG/ML SUBQ Caspofungin ACET SOL RECON 50 MG IV 1 + BD Caspofungin ACET SOL RECON 70 MG IV 1 + BD DESO/ETHINYL TAB ESTRADIO DiazePAM GEL 10 MG RCT DiazePAM GEL 2.5 MG RCT Estradiol TAB 10 MCG VAG IDHIFA TAB 100 MG IDHIFA TAB 50 MG 62/31 + Isentress HD TAB 600 MG 62/31 ISIBLOOM TAB LIDOCAINE INJ 0.5% Page 1 of 9

2 pharmacies, - Non-Formulary, PA - Prior Authorization, QL Quantity Limit per 30 days, ST - Step Therapy Last Updated: 03/24/ Effective date: 04/01/ Lynparza TAB 100 MG LA Lynparza TAB 150 MG LA Mavyret TAB MG 1 + PA1 MEROPENEM INJ 1GM MOXIFLOXACIN SOL 0.5% NALOXONE HYDROCHLORIDE 40 MG/ML NASAL SPRAY [NARCAN] 2 Nerlynx TAB 40 MG 186/ LA Olopatadine HCl SOL 0.2 % OPH ORFADIN CAP 20MG 1 + PA1 PEG 3350 SOL ELECTROL Radicava SOL 30 MG/100ML IV 1 + PA1 SEVELAMER TAB 800MG 540/31 Vigabatrin PACK 500 MG 186/31 + LA Vyxeos SUSP RECON MG IV 1 + XATMEP SOL 2.5MG/ML 1 + BD Xifaxan TAB 200 MG 9 + Zytiga TAB 500 MG 124/31 EFFECTIVE 03/01/ Adacel SUSPENSION LF-MCG/0.5 Intramuscular (prefilled syringe) Aliqopa SOLUTION RECONSTITUTED 60 MG LA Page 2 of 9

3 pharmacies, - Non-Formulary, PA - Prior Authorization, QL Quantity Limit per 30 days, ST - Step Therapy Aminosyn II SOL 7 % IV 1 + BD CMS Required Deletion Ampicillin CAP 250 MG 1 CMS Required Deletion Ampicillin SUS 125 MG/5ML 1 CMS Required Deletion Ampicillin SUS 250 MG/5ML 1 CMS Required Deletion ARIPiprazole SOLUTION MG/ML ORAL Austedo TABLET PA1 Austedo TABLET PA1 Austedo TABLET PA1 Bortezomib SOLUTION RECONSTITUTED 3.5 MG Bosulif TABLET Bromfenac Sodium SOL 0.09 % OPH 1 CMS Required Deletion Budesonide SUS 32 MCG/ACT Nasal 1 CMS Required Deletion Calquence CAPSULE 100 MG 62/31 + Oral + LA DACTINomycin SOLUTION RECONSTITUTED 0.5 MG 1 + BD Efavirenz CAPSULE /31 Ethynodiol Diac-Eth Estradiol TABLET 1-35 MG-MCG Oral Fosamprenavir Calcium TABLET /31 Last Updated: 03/24/ Effective date: 04/01/ Page 3 of 9

4 pharmacies, - Non-Formulary, PA - Prior Authorization, QL Quantity Limit per 30 days, ST - Step Therapy Glatiramer Acetate Solution Prefilled Syringe 20 MG/ML Subcutaneous Glatiramer Acetate Solution Prefilled Syringe 40 MG/ML Subcutaneous Haloperidol Decanoate SOLUTION 100 MG/ML Intramuscular 1 ML Havrix SUSPENSION 1440 EL U/ML Intramuscular (prefilled syringe) Havrix SUSPENSION 720 EL U/0.5ML Intramuscular (prefilled syringe) Last Updated: 03/24/ Effective date: 04/01/ PA1 12/28 + PA1 Juluca TABLET /31 Kadcyla SOLUTION RECONSTITUTED 160 MG 1 + Lartruvo SOLUTION 190 MG/19ML 1 + Levo-T TABLET 100 MCG ORAL Levo-T TABLET 112 MCG ORAL Levo-T TABLET 125 MCG ORAL Levo-T TABLET 137 MCG ORAL Levo-T TABLET 150 MCG ORAL Levo-T TABLET 175 MCG ORAL Levo-T TABLET 200 MCG ORAL Levo-T TABLET 25 MCG ORAL Page 4 of 9

5 pharmacies, - Non-Formulary, PA - Prior Authorization, QL Quantity Limit per 30 days, ST - Step Therapy Levo-T TABLET 300 MCG ORAL Levo-T TABLET 50 MCG ORAL Levo-T TABLET 75 MCG ORAL Levo-T TABLET 88 MCG ORAL Lomedia 24 FE TAB 1-20 MG- MCG(24) 1 CMS Required Deletion Lupron Depot-Ped (3-Month) KIT 30 MG (Ped) Intramuscular 1/90 + Menomune INJECTABLE SQ 1 CMS Required Deletion Methotrexate Sodium (PF) SOLUTION 250 MG/10ML INJECTION 1 + BD Mylotarg SOLUTION RECONSTITUTED 4.5 MG LA Necon 10/11 (28) TAB 35 MCG 1 CMS Required Deletion Novarel SOLUTION RECONSTITUTED 5000 UNIT Intramuscular 1 + PA1 Opdivo SOLUTION 100 MG/10ML Opdivo SOLUTION 40 MG/4ML Oseltamivir Phosphate SUSPENSION RECONSTITUTED 6 MG/ML Oral /31 Last Updated: 03/24/ Effective date: 04/01/ Page 5 of 9

6 pharmacies, - Non-Formulary, PA - Prior Authorization, QL Quantity Limit per 30 days, ST - Step Therapy Oxaliplatin SOLUTION RECONSTITUTED 100 MG Piperacillin Sod-Tazobactam So SOLUTION RECONSTITUTED 2.25 (2-0.25) GM Rexulti TABLET 0.25 MG ORAL Rexulti TABLET 0.5 MG ORAL Rexulti TABLET 1 MG ORAL Rexulti TABLET 2 MG ORAL Rexulti TABLET 3 MG ORAL Rexulti TABLET 4 MG ORAL Rituxan SOLUTION 100 MG/10ML Scopolamine Patch 72 Hour 1 MG/3DAYS Transdermal 1 + BD 1 + BD 31/31 31/31 31/31 31/31 31/31 31/ Last Updated: 03/24/ Effective date: 04/01/ Page 6 of 9

7 pharmacies, - Non-Formulary, PA - Prior Authorization, QL Quantity Limit per 30 days, ST - Step Therapy Last Updated: 03/24/ Effective date: 04/01/ Stelara SOLUTION 45 MG/0.5ML Subcutaneous 1 + ST1 SUMAtriptan Succinate SOL PFS 6 MG/0.5ML SQ 6/28 CMS Required Deletion Timolol Maleate SOLUTION 0.5 % (DAILY) Ophthalmic Tracleer TABLET SOLUBLE PA1 Treanda SOLUTION RECONSTITUTED 25 MG 1 + BD Trisenox SOLUTION 12 MG/6ML 1 + BD Vaqta SUSPENSION 25 UNIT/0.5ML Intramuscular (injection) Vaqta SUSPENSION 50 UNIT/ML Intramuscular (injection) Varubi TABLET 90 MG ORAL 4/28 + BD Verzenio TABLET LA Verzenio TABLET LA Verzenio TABLET LA Verzenio TABLET LA Xuriden PACKET 2 GM ORAL 1 + PA1 Zenchent FE TAB CHEWABLE MG-MCG Zenpep CAPSULE DELAYED RELEASE PARTICLES UNIT Oral 1 CMS Required Deletion Page 7 of 9

8 pharmacies, - Non-Formulary, PA - Prior Authorization, QL Quantity Limit per 30 days, ST - Step Therapy EFFECTIVE 04/01/ Altavera TABLET MG- MCG ORAL Alunbrig TABLET 180 Alunbrig TABLET 90 Alunbrig Tablet Therapy Pack 90 & 180 Atazanavir Sulfate CAPSULE 150 Atazanavir Sulfate CAPSULE 200 Atazanavir Sulfate CAPSULE 300 Doripenem SOLUTION RECONSTITUTED 500 MG Eliquis Starter Pack TABLET 5 Enskyce TABLET MG- MCG ORAL Estradiol CREAM 0.1 MG/GM Vaginal Herceptin SOLUTION RECONSTITUTED 150 MG Kurvelo TABLET MG- MCG ORAL 62/ /31 62/31 31/ BD 1 + BD Last Updated: 03/24/ Effective date: 04/01/ Page 8 of 9

9 pharmacies, - Non-Formulary, PA - Prior Authorization, QL Quantity Limit per 30 days, ST - Step Therapy Levonorgestrel-Ethinyl Estrad TABLET MG-MCG ORAL MedroxyPROGESTERone Acetate Suspension Prefilled Syringe 150 MG/ML Intramuscular Roweepra XR Tablet Extended Release 24 Hour 500 Roweepra XR Tablet Extended Release 24 Hour 750 Selzentry SOLUTION 20 MG/ML Oral Shingrix SUSPENSION RECONSTITUTED 50 MCG Intramuscular Tenofovir Disoproxil Fumarate TABLET 300 Zenpep CAPSULE DELAYED RELEASE PARTICLES UNIT Oral Zenpep CAPSULE DELAYED RELEASE PARTICLES UNIT Oral 1860/31 31/31 1 CMS Required Deletion Last Updated: 03/24/ Effective date: 04/01/ Page 9 of 9

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