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HAP/Midwest Health Plan, MI Medicaid Common Formulary …...HAP/Midwest Health Plan, MI Medicaid...
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HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 1 UPDATED 10/2018 October, 2012 Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2012 MONONINE,BEN EFIX,PROFILNIN E SD,ALPHANINE SD,RIXUBIS,ALP ROLIX,IXINITY,I DELVION,REBIN YN factor ix,factor ix human recombinant,factor ix complex human,factor ix recombinant, fc fusion protein,factor ix human recombinant, threonine 148,factor ix recombinant,albumin fusion protein,factor ix (human) recombinant, pegylated ADD UM: CUSTOM Carveout Drug - Bill MDCH FFS 10/01/2012 KALBITOR ecallantide ADD UM: CUSTOM Carveout Drug - Bill MDCH FFS
Transcript of HAP/Midwest Health Plan, MI Medicaid Common Formulary …...HAP/Midwest Health Plan, MI Medicaid...
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 1 UPDATED 10/2018
October, 2012
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2012 MONONINE,BEN
EFIX,PROFILNIN E SD,ALPHANINE SD,RIXUBIS,ALP ROLIX,IXINITY,I DELVION,REBIN YN
factor ix,factor ix human recombinant,factor ix complex human,factor ix recombinant, fc fusion protein,factor ix human recombinant, threonine 148,factor ix recombinant,albumin fusion protein,factor ix (human) recombinant, pegylated
ADD UM: CUSTOM Carveout Drug - Bill MDCH FFS
10/01/2012 KALBITOR ecallantide ADD UM: CUSTOM Carveout Drug - Bill MDCH FFS
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 2 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
10/01/2012 sprycel,bosulif,inl yta,sutent,xalkori, gleevec,tasigna,t ykerb,votrient,ires sa,vandetanib,ca prelsa,cometriq,t arceva,zelboraf,st ivarga,nexavar,ve lcade,kyprolis,iclu sig,tafinlar,gilotrif, imbruvica,zykadi a,zydelig,lynparz a,ibrance,lenvima ,tagrisso,ninlaro,a lecensa,imatinib mesylate,cabome tyx,rubraca,kisqal i,zejula,rydapt,alu nbrig,nerlynx,aliq opa,verzenio,calq uence,bortezomi b
dasatinib,bosutinib,axitinib,s unitinib malate,crizotinib,imatinib mesylate,nilotinib hcl,lapatinib ditosylate,pazopanib hcl,gefitinib,vandetanib,cabo zantinib s-malate,erlotinib hcl,vemurafenib,regorafenib, sorafenib tosylate,bortezomib,carfilzo mib,ponatinib hcl,dabrafenib mesylate,afatinib dimaleate,ibrutinib,ceritinib,i delalisib,olaparib,palbociclib, lenvatinib mesylate,osimertinib mesylate,ixazomib citrate,alectinib hcl,rucaparib camsylate,ribociclib succinate,niraparib tosylate,midostaurin,brigatini b,neratinib maleate,copanlisib di- hcl,abemaciclib,acalabrutini b
ADD UM: CUSTOM Carveout Drug - Bill MDCH FFS
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 3 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
10/01/2012 albuminar- 5,albuminar- 25,buminate,flexb umin,thrombate iii,plasmanate,pla sbumin- 25,plasbumin- 5,alburx,albumin (human),atryn,alb utein,albuked- 25,albuked- 5,kedbumin,octap las
albumin human,antithrombin iii (human plasma derived),plasma protein fraction,antithrombin iii, human recombinant,plasma human, blood group a,plasma human, blood group b,plasma human, blood group ab,plasma human, blood group o
ADD UM: CUSTOM Carveout Drug - Bill MDCH FFS
10/01/2012 CEPROTIN protein c, human ADD UM: CUSTOM Carveout Drug - Bill MDCH FFS
10/01/2012 cyklokapron,amin ocaproic acid,tranexamic acid,amicar,lyste da,riastap,trasylol ,fibryga
tranexamic acid,aminocaproic acid,fibrinogen,aprotinin
ADD UM: CUSTOM Carveout Drug - Bill MDCH FFS
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 4 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
10/01/2012 KOGENATE FS,HUMATE- P,MONOCLATE- P,HELIXATE FS,NOVOSEVEN RT,NOVOSEVE N,RECOMBINAT E,ADVATE,HEM OFIL M,ADVATE L,ADVATE M,ADVATE H,ADVATE SH,ADVATE UH,KOATE- DVI,XYNTHA,XY NTHA SOLOFUSE,FEI BA VH IMMUNO,FEIBA NF,WILATE,ALP HANATE,REFAC TO,MONARC- M,ELOCTATE,O BIZUR,NOVOEI GHT,KOATE,NU WIQ,ADYNOVAT E,KOVALTRY,AF STYLA
antihemophilic factor, hum rec,antihemophilic factor (fviii) recomb,full length (alb- free),antihemophilic factor (fviii) recombinant,full length,antihemophilic factor, human/von willebrand factor,human,antihemophilic factor, human,antihemophilic factor viii, human recombinant,coagulation factor viia (recombinant),antihemophili c factor (factor viii) recomb,b-domain deleted,anti-inhibitor coagulant complex,antihemophilic factor (fviii) recombinant, fc fusion protein,antihemophilic factor viii, recombinant porcine sequence,antihemophilic factor viii recombinant, b- domain truncated,antihemophilic factor viii rec hek cell, b- domain deleted,antihemophilic factor (fviii) recombinant, full length, peg,antihemophilic factor viii recomb,single- chn,b-dom truncated
ADD UM: CUSTOM Carveout Drug - Bill MDCH FFS
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 5 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
10/01/2012 levocarnitine,carn itor,carnitor sf,cystadane,sulf zix,xizflus,sod polysulthionate- folic acid,glygest
levocarnitine,levocarnitine (with sugar),betaine,sulfur/sodium sulfate/sodium thiosulf/methyltetrahydrofola te,sulfur/sodium sulfate/sodium thiosulfate/folic acid,fucosyllactose/lacto-n- neotetraose
ADD UM: CUSTOM Carveout Drug - Bill MDCH FFS
10/01/2012 KUVAN sapropterin dihydrochloride ADD UM: CUSTOM Carveout drug - Bill mDCH FFS
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 6 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
10/01/2012 gas-x prevention,lactras e,lactose fast acting,lactaid,lact aid fast act,lac- dose,milk digestant,lactase, lactase fast acting,ultra dairy digestive,dairy digestive,dairy relief,dairy aid,anti- gas,enzymatic digestant,digestiv e enzyme,milco- zyme,mm- zyme,lactase enzyme,dairy digest,digestive enzymes,beano,e nzyme digest,tri- zyme,lactaid extra strength,fast acting lactase,sucraid,d airy digestive supplement,lactai d ultra,betaine hcl,digex,gastrine x,enzymall,diges plen plus,dayto- anase,enzymax,b etazyme,lactose fast acting relief,superior digestive enzyme
alpha-d- galactosidase,lactase,lactas e/rennet,pepsin/amylase/ox bile extract/pancreatin/betaine hcl/papain,enzymes,digestiv e,pepsin/glutamic acid/betaine,amylase/cellula se/lipase/maltase/protease/l actase/invertase,lipase/lacta se/amylase,sacrosidase,pep sin/betaine hcl,cellulase/amylase/lipase/ protease/phenyltoloxamine/ hyoscy,pepsin/cellulase/sim ethicone/whole bile/pancreatin,cellulase/am ylase/lipase/protease,protea se/betaine hcl,digestive enzymes combo no.7,digestive enzymes combo no.8/l. acidophilus/pectin, citrus
ADD UM: CUSTOM Carveout Drug - Bill MDCH FFS
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 7 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
10/01/2012 ORFADIN,NITYR nitisinone ADD UM: CUSTOM Carveout Drug - Bill MDCH FFS
10/01/2012 lithostat,enulose, sodium phenylbutyrate,la ctulose,carbaglu, generlac,buphen yl,ammonul,ravict i,sodium phenylacet-sod benzoate
acetohydroxamic acid,lactulose,sodium phenylbutyrate,carglumic acid,sodium benzoate/sodium phenylacetate,glycerol phenylbutyrate
ADD UM: CUSTOM Carveout Drug - Bill MDCH FFS
10/01/2012 VONVENDI von willebrand factor (recombinant)
ADD UM: CUSTOM Carveout Drug - Bill MDCH FFS
10/01/2012 MONONINE,BEN EFIX,PROFILNIN E SD,ALPHANINE SD,RIXUBIS,ALP ROLIX,IXINITY,I DELVION,REBIN YN
factor ix,factor ix human recombinant,factor ix complex human,factor ix recombinant, fc fusion protein,factor ix human recombinant, threonine 148,factor ix recombinant,albumin fusion protein,factor ix (human) recombinant, pegylated
CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
Carveout Drug - Bill MDCH
10/01/2012 PANHEMATIN hemin ADD UM: CUSTOM Carveout Drug - Bill MDCH
10/01/2012 SOLIRIS eculizumab ADD UM: CUSTOM Carveout Drug - Bill MDCH
10/01/2012 CINRYZE,BERIN ERT,RUCONEST ,HAEGARDA
c1 esterase inhibitor,c1 esterase inhibitor, recombinant
ADD UM: CUSTOM Carveout Drug - Bill MDCH
10/01/2012 cortrosyn,cosyntr opin,acthrel,h.p. acthar
cosyntropin,corticorelin ovine triflutate,corticotropin
ADD UM: CUSTOM Carveout Drug - Bill MDCH
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 8 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
10/01/2012 KINERET,ARCA LYST
anakinra,rilonacept ADD UM: CUSTOM Carveout Drug - Bill MDCH
10/01/2012 zavesca,cerdelga ,miglustat
miglustat,eliglustat tartrate ADD UM: CUSTOM Carveout Drug - Bill MDCH
10/01/2012 FABRAZYME agalsidase beta ADD UM: CUSTOM Carveout Drug - Bill MDCH
10/01/2012 ELELYSO,VPRIV ,CEREDASE,CE REZYME
taliglucerase alfa,velaglucerase alfa,alglucerase,imigluceras e
ADD UM: CUSTOM Carveout Drug - Bill MDCH
10/01/2012 ELAPRASE,ALD URAZYME,NAGL AZYME,VIMIZIM, MEPSEVII
idursulfase,laronidase,galsul fase,elosulfase alfa,vestronidase alfa-vjbk
ADD UM: CUSTOM Carveout Drug - Bill MDCH
10/01/2012 ADAGEN pegademase bovine ADD UM: CUSTOM Carveout Drug - Bill MDCH
10/01/2012 MYOZYME,LUMI ZYME
alglucosidase alfa ADD UM: CUSTOM Carveout Drug - Bill MDCH
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 9 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
10/02/2012 sprycel,bosulif,inl yta,sutent,xalkori, gleevec,tasigna,t ykerb,votrient,ires sa,vandetanib,ca prelsa,cometriq,t arceva,zelboraf,st ivarga,nexavar,ve lcade,kyprolis,iclu sig,tafinlar,gilotrif, imbruvica,zykadi a,zydelig,lynparz a,ibrance,lenvima ,tagrisso,ninlaro,a lecensa,imatinib mesylate,cabome tyx,rubraca,kisqal i,zejula,rydapt,alu nbrig,nerlynx,aliq opa,verzenio,calq uence,bortezomi b
dasatinib,bosutinib,axitinib,s unitinib malate,crizotinib,imatinib mesylate,nilotinib hcl,lapatinib ditosylate,pazopanib hcl,gefitinib,vandetanib,cabo zantinib s-malate,erlotinib hcl,vemurafenib,regorafenib, sorafenib tosylate,bortezomib,carfilzo mib,ponatinib hcl,dabrafenib mesylate,afatinib dimaleate,ibrutinib,ceritinib,i delalisib,olaparib,palbociclib, lenvatinib mesylate,osimertinib mesylate,ixazomib citrate,alectinib hcl,rucaparib camsylate,ribociclib succinate,niraparib tosylate,midostaurin,brigatini b,neratinib maleate,copanlisib di- hcl,abemaciclib,acalabrutini b
CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 10 UPDATED 10/2018
April, 2013
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/01/2013 KALYDECO ivacaftor ADD UM: CUSTOM Carveout Drug -
Bill MDCH FFS
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 11 UPDATED 10/2018
February, 2014
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/10/2014 CORIFACT,TRE
TTEN factor xiii,factor xiii a- subunit, recombinant
ADD UM: CUSTOM Carveout Drug - Bill MDCH FFS
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 12 UPDATED 10/2018
November, 2014
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/03/2014 TYBOST cobicistat ADD UM: CUSTOM Carveout Drug -
Bill MDCH FFS
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 13 UPDATED 10/2018
January, 2016
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2016 nitroglycerin nitroglycerin ADD TO FORMULARY Covered 01/01/2016 nitroglycerin nitroglycerin ADD TO FORMULARY Covered 01/01/2016 constulose lactulose ADD TO FORMULARY Covered 01/01/2016 cetirizine hcl cetirizine hcl CHANGE TIER Covered 01/01/2016 cetirizine hcl cetirizine hcl CHANGE UM: QUANTITY 300 / 30 days 01/01/2016 cetirizine hcl cetirizine hcl ADD UM: AGE 0 to 12 yrs old 01/01/2016 cetirizine
hcl,children's all day allergy,children's wal-zyr,wal- zyr,children's zyrtec,all day allergy,children's allergy relief,children's cetirizine hcl,children's allergy,children's allergy complete,children 's aller- tec,children's zyrtec hives relief,zyrtec,allerg y relief
cetirizine hcl ADD UM: QUANTITY 300 / 30 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 14 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
01/01/2016 cetirizine hcl,children's all day allergy,children's wal-zyr,wal- zyr,children's zyrtec,all day allergy,children's allergy relief,children's cetirizine hcl,children's allergy,children's allergy complete,children 's aller- tec,children's zyrtec hives relief,zyrtec,allerg y relief
cetirizine hcl ADD UM: AGE 0 to 12 yrs old
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 15 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
01/01/2016 cetirizine hcl,children's all day allergy,children's wal-zyr,wal- zyr,children's zyrtec,all day allergy,children's allergy relief,children's cetirizine hcl,children's allergy,children's allergy complete,children 's aller- tec,children's zyrtec hives relief,zyrtec,allerg y relief
cetirizine hcl REMOVE UM: AGEQUANTITY
01/01/2016 laxative sennosides ADD TO FORMULARY Covered 01/01/2016 laxative
maximum strength
sennosides ADD TO FORMULARY Covered
01/01/2016 senna laxative sennosides ADD TO FORMULARY Covered 01/01/2016 natural laxative sennosides ADD TO FORMULARY Covered 01/01/2016 laxative
pills,laxative sennosides ADD TO FORMULARY Covered
01/01/2016 EX-LAX MAXIMUM STRENGTH
sennosides ADD TO FORMULARY Covered
01/01/2016 senna-extra sennosides ADD TO FORMULARY Covered 01/01/2016 SENOKOTXTRA sennosides ADD TO FORMULARY Covered 01/01/2016 SENOKOT sennosides ADD TO FORMULARY Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 16 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
01/01/2016 CORRECTOL bisacodyl ADD TO FORMULARY Covered 01/01/2016 DULCOLAX bisacodyl ADD TO FORMULARY Covered 01/01/2016 senexon sennosides ADD TO FORMULARY Covered 01/01/2016 SENOKOT sennosides ADD TO FORMULARY Covered 01/01/2016 EX-LAX sennosides ADD TO FORMULARY Covered 01/01/2016 PERDIEM sennosides ADD TO FORMULARY Covered 01/01/2016 CORRECTOL bisacodyl REMOVE FROM
FORMULARY Covered Non-Formulary
01/01/2016 gentle laxative,laxative
bisacodyl ADD TO FORMULARY Covered
01/01/2016 laxative feminine bisacodyl ADD TO FORMULARY Covered 01/01/2016 women's laxative bisacodyl ADD TO FORMULARY Covered 01/01/2016 women's
laxative,woman's laxative
bisacodyl ADD TO FORMULARY Covered
01/01/2016 alophen pills bisacodyl ADD TO FORMULARY Covered 01/01/2016 bisa-lax bisacodyl ADD TO FORMULARY Covered 01/01/2016 gentle laxative bisacodyl ADD TO FORMULARY Covered 01/01/2016 women's gentle
laxative bisacodyl ADD TO FORMULARY Covered
01/01/2016 ducodyl bisacodyl ADD TO FORMULARY Covered 01/01/2016 DULCOLAX bisacodyl REMOVE FROM
FORMULARY Covered Non-Formulary
01/01/2016 woman's laxative,women's laxative
bisacodyl ADD TO FORMULARY Covered
01/01/2016 laxative bisacodyl ADD TO FORMULARY Covered 01/01/2016 women's laxative bisacodyl ADD TO FORMULARY Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 17 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
01/01/2016 bisacodyl bisacodyl ADD TO FORMULARY Covered 01/01/2016 bisacodyl bisacodyl ADD TO FORMULARY Covered 01/01/2016 bisacodyl bisacodyl ADD TO FORMULARY Covered 01/01/2016 biscolax bisacodyl ADD TO FORMULARY Covered 01/01/2016 gentle laxative bisacodyl ADD TO FORMULARY Covered 01/01/2016 bisacodyl bisacodyl ADD TO FORMULARY Covered 01/01/2016 senna laxative sennosides ADD TO FORMULARY Covered 01/01/2016 natural
laxative,natural vegetable laxative
sennosides ADD TO FORMULARY Covered
01/01/2016 senno sennosides ADD TO FORMULARY Covered 01/01/2016 SENOKOT sennosides REMOVE FROM
FORMULARY Covered Non-Formulary
01/01/2016 EX-LAX sennosides REMOVE FROM FORMULARY
Covered Non-Formulary
01/01/2016 laxative pills sennosides ADD TO FORMULARY Covered 01/01/2016 PERDIEM sennosides REMOVE FROM
FORMULARY Covered Non-Formulary
01/01/2016 SENOKOT sennosides REMOVE FROM FORMULARY
Covered Non-Formulary
01/01/2016 SENOKOTXTRA sennosides REMOVE FROM FORMULARY
Covered Non-Formulary
01/01/2016 EX-LAX MAXIMUM STRENGTH
sennosides REMOVE FROM FORMULARY
Covered Non-Formulary
01/01/2016 senexon sennosides ADD TO FORMULARY Covered 01/01/2016 senna sennosides ADD TO FORMULARY Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 18 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
01/01/2016 senna lax sennosides ADD TO FORMULARY Covered 01/01/2016 natural senna
laxative sennosides ADD TO FORMULARY Covered
01/01/2016 sen-o-tab sennosides ADD TO FORMULARY Covered 01/01/2016 bisacodyl bisacodyl REMOVE FROM
FORMULARY Covered Non-Formulary
01/01/2016 gentle laxative bisacodyl REMOVE FROM FORMULARY
Covered Non-Formulary
01/01/2016 bisacodyl bisacodyl REMOVE FROM FORMULARY
Covered Non-Formulary
01/01/2016 bisacodyl bisacodyl ADD TO FORMULARY Non-Formulary Covered 01/01/2016 senna sennosides ADD TO FORMULARY Covered 01/01/2016 gentle laxative bisacodyl ADD TO FORMULARY Non-Formulary Covered 01/01/2016 laxative
suppository,fast relief laxative
bisacodyl ADD TO FORMULARY Covered
01/01/2016 DULCOLAX bisacodyl ADD TO FORMULARY Covered 01/01/2016 magic bullet bisacodyl ADD TO FORMULARY Covered 01/01/2016 laxative sennosides ADD TO FORMULARY Covered 01/01/2016 bisacodyl bisacodyl ADD TO FORMULARY Non-Formulary Covered 01/01/2016 ex-lax sennosides ADD TO FORMULARY Covered 01/01/2016 DULCOLAX bisacodyl ADD TO FORMULARY Non-Formulary Covered 01/01/2016 DULCOLAX bisacodyl CHANGE TIER Covered Not Covered 01/01/2016 DULCOLAX bisacodyl CHANGE TIER Not Covered Covered 01/01/2016 bisacodyl bisacodyl REMOVE FROM
FORMULARY Covered Non-Formulary
01/01/2016 magic bullet bisacodyl REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 19 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
01/01/2016 SENOKOT sennosides ADD TO FORMULARY Non-Formulary Covered 01/01/2016 EX-LAX sennosides ADD TO FORMULARY Non-Formulary Covered 01/01/2016 SENOKOT sennosides REMOVE FROM
FORMULARY Covered Non-Formulary
01/01/2016 EX-LAX sennosides REMOVE FROM FORMULARY
Covered Non-Formulary
01/01/2016 laxative sennosides REMOVE FROM FORMULARY
Covered Non-Formulary
01/01/2016 ex-lax sennosides REMOVE FROM FORMULARY
Covered Non-Formulary
01/01/2016 SYSTANE propylene glycol/polyethylene glycol 400
ADD TO FORMULARY Covered
01/01/2016 SYSTANE ULTRA
propylene glycol/polyethylene glycol 400
ADD TO FORMULARY Covered
01/01/2016 eye itch relief ketotifen fumarate CHANGE TIER Covered 01/01/2016 itchy eye ketotifen fumarate CHANGE TIER Covered 01/01/2016 ALAWAY ketotifen fumarate REMOVE FROM
FORMULARY Covered Non-Formulary
01/01/2016 refresh,zaditor,ke totifen fumarate,eye itch relief,wal- zyr,zyrtec itchy eye,itchy eye,children's alaway,alaway,all ergy eye,allergy eye drops,antihistami ne eye drops
ketotifen fumarate CHANGE UM: QUANTITY 0.3 / 1 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 20 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
01/01/2016 azelastine hcl azelastine hcl CHANGE TIER Covered 01/01/2016 optivar,azelastine
hcl azelastine hcl ADD UM: QUANTITY 6 / 30 days
01/01/2016 VEMLIDY tenofovir alafenamide fumarate
ADD TO FORMULARY Covered
01/01/2016 VEMLIDY tenofovir alafenamide fumarate
ADD UM: QUANTITY 30 / 30 days
01/01/2016 vancomycin hcl vancomycin hcl CHANGE TIER Covered 01/01/2016 vancomycin hcl vancomycin hcl CHANGE TIER Covered 01/01/2016 vancomycin hcl vancomycin hcl CHANGE TIER Covered 01/01/2016 vancomycin hcl vancomycin hcl CHANGE TIER Covered 01/01/2016 calcidol ergocalciferol (vitamin d2) ADD TO FORMULARY Covered 01/01/2016 reyataz,invirase,c
rixivan,norvir,lexiv a,viracept,evotaz, fosamprenavir calcium,atazanav ir sulfate,ritonavir
atazanavir sulfate,saquinavir mesylate,indinavir sulfate,ritonavir,fosamprena vir calcium,nelfinavir mesylate,atazanavir sulfate/cobicistat
ADD UM: CUSTOM MDHHS Carve- Out
01/01/2016 PANCREAZE lipase/protease/amylase ADD UM: QUANTITY 720 / 30 days 01/01/2016 ZENPEP lipase/protease/amylase ADD TO FORMULARY Covered 01/01/2016 ZENPEP lipase/protease/amylase ADD UM: QUANTITY 480 / 30 days 01/01/2016 PANCREAZE lipase/protease/amylase ADD TO FORMULARY Covered 01/01/2016 PANCREAZE lipase/protease/amylase ADD UM: QUANTITY 720 / 30 days 01/01/2016 CREON lipase/protease/amylase CHANGE UM: QUANTITY 42.1 / day 720 / 30 days 01/01/2016 ZENPEP lipase/protease/amylase ADD UM: QUANTITY 720 / 30 days 01/01/2016 CREON lipase/protease/amylase CHANGE UM: QUANTITY 336.67 / day 480 / 30 days 01/01/2016 ZENPEP lipase/protease/amylase CHANGE UM: QUANTITY 336.67 / day 480 / 30 days 01/01/2016 CREON lipase/protease/amylase CHANGE UM: QUANTITY 90.9 / day 720 / 30 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 21 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
01/01/2016 PANCREAZE lipase/protease/amylase CHANGE UM: QUANTITY 720 / 30 days 480 / 30 days 01/01/2016 SYNJARDY empagliflozin/metformin hcl ADD UM: QUANTITY 2 / 1 days 01/01/2016 SYNJARDY empagliflozin/metformin hcl ADD UM: QUANTITY 2 / 1 days 01/01/2016 SYNJARDY XR empagliflozin/metformin hcl ADD UM: QUANTITY 2 / 1 days 01/01/2016 SYNJARDY XR empagliflozin/metformin hcl ADD UM: QUANTITY 2 / 1 days 01/01/2016 SYNJARDY XR empagliflozin/metformin hcl ADD UM: QUANTITY 1 / 1 days 01/01/2016 SYNJARDY XR empagliflozin/metformin hcl ADD UM: QUANTITY 1 / 1 days 01/01/2016 SYNJARDY empagliflozin/metformin hcl ADD UM: QUANTITY 2 / 1 days 01/01/2016 SYNJARDY empagliflozin/metformin hcl ADD UM: QUANTITY 2 / 1 days 01/01/2016 fentanyl fentanyl CHANGE TIER Covered 01/01/2016 fentanyl fentanyl CHANGE TIER Covered 01/01/2016 fentanyl fentanyl CHANGE TIER Covered 01/01/2016 fentanyl fentanyl CHANGE TIER Covered 01/01/2016 fentanyl fentanyl CHANGE TIER Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 22 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
01/01/2016 flulaval,flulaval 2011- 2012,flulaval 2012- 2013,afluria,afluri a 2011-2012 (pf),afluria 2012- 2013,afluria 2011- 2012,influenza a (h1n1) 2009,agriflu,fluzo ne,fluzone 2011- 2012 (pf),fluzone 2012- 2013,fluzone pedi 2012- 2013,fluzone high-dose,fluzone 2011- 2012,fluzone high-dose 2011- 12 (pf),fluzone high-dose 2012- 13,fluzone intradermal,fluzo ne intradermal 2012- 2013,fluarix,fluari x 2011- 2012,fluarix 2012- 2013,flucelvax,flu mist,fluvirin,fluviri n 2011- 2012,fluvirin 2012- 2013,physicians ez use flu 2012-
influenza virus vaccine tri- split 2009-2010,influenza virus vaccine tri-split 2010- 2011,influenza virus vaccine tv split 2011-2012 (18 yr & older),influenza virus vaccine tv split 2012-2013 (18 yr & older),influenza virus vaccine trivalent-split 2009-2010/pf,influenza virus vaccine trivalent-split 2010- 2011/pf,influenza virus vaccine tv split 2011-2012 (9 yr & older)/pf,influenza virus vaccine tv split 2012-2013 (5 yr & older)/pf,influenza virus vaccine tv split 2011-2012 (9 yr & older),influenza virus vaccine tv split 2012-2013 (5 yr & older),influenza a (h1n1) virus vaccine monovalent 2009/pf,influenza a (h1n1) virus vaccine monovalent 2009,influenza virus vaccine tv-sp 2011-12 (36 mos and older)/pf,influenza virus vaccine tvs 2012-2013 (36 mos and older)/pf,influenza virus vaccine 2011-2012 (6 mos-35 mos)/pf,influenza virus vaccine 2012-2013 (6 mos-35 mos)/pf,influenza virus vaccine tv split 2011- 2012 (6 mos and older),influenza virus vaccine trivalent-split 2011- 2012/pf,influenza virus vaccine tv split 2012 2013
ADD TO FORMULARY Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 23 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
13,fluzone quad mos and older),influenza 2013- virus vaccine trivalent-split2014,fluzone 2012-2013quad pedi 2013- (65yr+)/pf,influenza virus2014,single use vaccine tvs 2012-2013 (18ez flu 2012- yrs-64 yrs)/pf,influenza virus2013,fluzone vaccine tv split 2011-2012 (32013- yr & older)/pf,influenza virus2014,fluzone pedi vaccine tv split 2012-2013 (32013- yr & older)/pf,influenza2014,fluzone vaccine tri-splt 2012-13(18high-dose 2013- yr +)cell derived/pf,influenza2014,fluzone virus vaccine trivalent 2009-intradermal 2013- 2010 (live),influenza virus2014,single use vaccine trivalent 2010-2011ez flu 2013- (live),influenza virus vaccine2014,fluarix quad trivalent 2011-20122013-2014,afluria (live),influenza virus vaccine2013- tv live 2012-2013 (2 yrs-492014,fluvirin yrs),influenza-a (h1n1) virus2013- vaccine monovalent 20092014,flulaval (live),influenza virus vaccine2013-2014,fluarix tv split 2011-2012 (4 yr &2013- older)/pf,influenza virus2014,flulaval vaccine tv split 2011-2012 (4quad 2013- yr & older),influenza virus2014,flublok vaccine tv split 2012-2013 (42012- yr & older)/pf,influenza virus2013,flublok vaccine tv split 2012-2013 (42013- yr & older),influenza virus2014,flucelvax vaccine qval live 2013-20142014- (2 yrs-49 yrs),influenza virus2015,fluzone vaccine quad vs 2013-14(36high-dose 2014- mos and older)/pf,influenza2015,flulaval virus vaccine quad vs 2013-quad 2014- 2014 (6 mos-352015,flulaval mos)/pf,influenza virus2014- vaccine tvs 2013-2014 (362015,flublok mos and older)/pf,influenza
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 24 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
2014- virus vaccine tvs 2013-2014 2015,fluzone (6 mos-35 mos)/pf,influenzaquad pedi 2014- virus vaccine tri-split 2013-2015,fluzone 14 (6 mos andintradermal 2014- older),influenza virus2015,fluarix vaccine tvs 2013-2014 (652014-2015,fluarix yr and up)/pf,influenza virusquad 2014- vaccine tvs 2013-2014 (182015,fluzone yrs-64 yrs)/pf,influenza virus2014- vaccine tv split 2013-14 (5 yr2015,fluzone and older)/pf,influenza virusquad 2014- vaccine tv split 2013-2014 (52015,fluvirin yr and older),influenza2014- vaccine tv split 2013-14(182015,flumist quad yr,up) cell2014-2015,afluria derived/pf,influenza virus2014-2015,single vaccine tv split 2013-2014 (4use ez flu 2014- yr and up)/pf,influenza virus2015,fluzone vaccine tv split 2013-2014 (4intraderm quad yr and older),influenza virus2015-16,fluzone vaccine tvs 2013-2014 (362015- mos and older),influenza2016,fluzone virus vaccine quad vs 2013-high-dose 2015- 2014 (36 mos and2016,fluzone older),influenza virusquad 2015- vaccine tv 2012-2013 (18 to2016,fluzone 49 yrs)recomb/pf,influenzaquad pedi 2015- virus vaccine tv 2013-20142016,flulaval (18 to 49quad 2015- yrs)recomb/pf,influenza tv-s2016,afluria 07-08 vaccine,influenza tv-s2015- 08-09 vaccine,influenza tv-s2016,flublok 07-08 vaccine/pf,influenza2015- tv-s 08-092016,flucelvax vaccine/pf,influenza vacc,tri2015- 2007(live),influenza vacc,tri2016,fluvirin 2008(live),influenza vaccine2015-2016,fluarix tv split 2014-15 (18quad 2015- yr,up)cell
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 25 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
2016,flumist quad derived/pf,influenza virus 2015-2016,ez flu vaccine trivalent 2014-20152015-2016 (65 yr,older)/pf,influenza(flucelvax),ez flu virus vaccine quad vs 2014-2015-2016 2015 (36 mos and(fluvirin),fluad older),influenza virus2015- vaccine trival 2014-15 (362016,flulaval mos and older)/pf,influenzaquad 2016- virus vaccine trivalent 2014-2017,afluria 15 (36 mos and2016- older),influenza virus2017,flublok vaccine quadrival 2014-2016-2017,fluarix 15(36 mos,quad 2016- older)/pf,influenza virus2017,flumist quad vaccine tv 2014-2015(182016- yrs,2017,fluvirin older)recomb/pf,influenza2016- virus vaccine quadrival2017,flucelvax 2014-15 (6 mos-35quad 2016- mos)/pf,influenza virus2017,fluzone vaccine trivalent 2014-15high-dose 2016- (18 yrs-64 yrs)/pf,influenza2017,fluzone virus vaccine trivalent 2014-quad 2016- 15 (6 mos and2017,fluzone older),influenza virusquad pedi 2016- vaccine quadrival 2014-2017,fluzone 2015(6 mos andintraderm quad older),influenza virus2016-17,fluad vaccine trivalnt 2014-20152016-2017,ez flu (4 yr, older)/pf,influenza2016-2017 virus vaccine trivalent 2014-(fluvirin),ez flu 2015 (4 yr and2016-2017 older),influenza vaccine(afluria),ez flu 16- quadrivalent live 2014-201517 (fluzon quad (2 yrs-49 yrs),influenza virusped),afluria quad vaccine trivalnt 2014-20152016- (5 yr, older)/pf,influenza2017,fluzone virus vaccine trivalent 2014-high-dose 2017- 2015 (5 yr and
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 26 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
2018,fluzone older),influenza virus quad 2017- vaccine quadrivalent 2015-2018,fluzone 16(18yrs-64yrs)/pf,influenzaquad pedi 2017- virus vaccine trivalent 2015-2018,fluzone 16 (6 mos andintraderm quad older),influenza virus2017-18,fluad vaccine trivalent split 2015-2017- 16(65 yr,up)/pf,influenza2018,fluvirin virus vaccine quadrival2017- split2015-16(362018,flucelvax mos,up)/pf,influenza virusquad 2017- vaccine quadrival 2015-162018,flublok (6 mos-35 mos)/pf,influenza2017- virus vaccine qvalsplit 2015-2018,flublok quad 2016(6 mos and2017-2018,afluria older),influenza virus2017-2018,afluria vaccine quadrival 2015-quad 2017- 2016 (36 mos,2018,flulaval older),influenza virusquad 2017- vaccine trivalnt 2015-20162018,fluarix quad (5 yr, older)/pf,influenza2017- virus vaccine trivalent 2015-2018,flumist quad 2016 (5 yr and2017- older),influenza virus2018,flulaval vaccine tv 2015-2016(18quad 2018- yrs,2019,fluzone older)recomb/pf,influenzaquad 2018- vaccine trivalent 2015-16(182019,fluarix quad yr,up)cell2018- derived/pf,influenza virus2019,flublok quad vaccine trivalent 2015-20162018- (4 yr, older)/pf,influenza2019,fluzone virus vaccine trivalent 2015-quad pedi 2018- 2016 (4 yr and2019,fluzone older),influenza vaccinehigh-dose 2018- quadrivalent live 2015-20162019,afluria (2 yrs-49 yrs),influenza2018-2019,afluria vaccine tvs 2015-16 (65quad 2018- yr,up)/adjuvant
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 27 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
2019,fluad 2018- 2019,flucelvax quad 2018- 2019,flumist quad 2018-2019
mf59c.1/pf,influenza virus vaccine qvalsplit 2016- 2017(6 mos and older),influenza virus vaccine qvalsplit 2016- 2017(6 mos and up)/pf,influenza virus vaccine trivalent 2016-2017 (5 years up)/pf,influenza virus vaccine trivalent 2016- 2017 (5 yr and older),influenza virus vaccine tv 2016-17(18 yrs and older)rcmb/pf,influenza virus vaccine quadval split 2016-17(36 mos up)/pf,influenza vaccine quadrivalent live 2016-2017 (2 yrs-49 yrs),influenza virus vaccine trival 2016-2017 (4yr and older)/pf,influenza virus vaccine trivalent 2016- 2017 (4 yr and older),flu vaccine qs 2016-2017(4 years and older)cell derived/pf,influenza virus vaccine trival split 2016- 2017(65 yr up)/pf,influenza virus vaccine quadrival 2016-17 (6 mos-35 mos)/pf,influenza virus vaccine quadrivalent 2016- 17(18yrs-64yrs)/pf,influenza vaccine tvs 2016-17 (65 yr up)/adjuvant mf59c.1/pf,influenza virus vaccine quadrivalent 2016- 17(18yr and up)/pf,influenza virus vaccine quadrivalent
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 28 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
2016-17(18 year and up),influenza virus vaccine trival split 2017-2018(65 yr up)/pf,influenza virus vaccine quadrivalent 2017- 18 (36 mos up)/pf,influenza virus vaccine quadrival 2017-18 (6 mos-35 mos)/pf,influenza virus vaccine quadrivalent 2017- 18 (6 mos and up),influenza virus vaccine quadrivalent 2017-18(18yrs- 64yrs)/pf,influenza vaccine tvs 2017-18 (65 yr up)/adjuvant mf59c.1/pf,influenza virus vaccine trival 2017-2018 (4yr and older)/pf,influenza virus vaccine trivalent 2017- 2018 (4 yr and older),flu vaccine quad 2017-2018(4 years and older)cell derived/pf,flu vaccine quadriv 2017-2018(4 years and older)cell derived,influenza virus vaccine tv 2017-18(18 yrs and older)rcmb/pf,influenza virus vaccine qv 2017-18(18 yrs and older)rcmb/pf,influenza virus vaccine trivalent 2017-2018 (5 years up)/pf,influenza virus vaccine trivalent 2017- 2018 (5 yr and older),influenza virus vaccine quadrivalent 2017- 18(5 yr and up)/pf,influenza
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 29 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
virus vaccine quadrivalent 2017-18 (5 year and up),influenza virus vaccine qvalsplit 2017-2018(6 mos and up)/pf,influenza vaccine quadrivalent live 2017-2018 (2 yrs-49 yrs),influenza virus vaccine quadrivalent 2018- 19 (6 mos and up),influenza virus vaccine quadrival 2018-2019(6 mos and up)/pf,influenza virus vaccine qv 2018-19(18 yrs and older)rcmb/pf,influenza virus vaccine quadrivalent 2018-19 (36 mos up)/pf,influenza virus vaccine quadrival 2018-19 (6 mos-35 mos)/pf,influenza virus vaccine trival split 2018-2019(65 yr up)/pf,influenza virus vaccine trivalent 2018-2019 (5 years up)/pf,influenza virus vaccine trivalent 2018- 2019 (5 yr and older),influenza virus vaccine quadrivalent 2018- 19(5 yr and up)/pf,influenza virus vaccine quadrivalent 2018-19 (5 year and up),influenza vaccine tvs 2018-19 (65 yr up)/adjuvant mf59c.1/pf,flu vaccine quad 2018-2019(4 years and older)cell derived/pf,flu vaccine quadriv 2018- 2019(4 years and older)cell derived influenza vaccine
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 30 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
quadrivalent live 2018-2019 (2 yrs-49 yrs)
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 31 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
01/01/2016 flulaval,flulaval 2011- 2012,flulaval 2012- 2013,afluria,afluri a 2011-2012 (pf),afluria 2012- 2013,afluria 2011- 2012,influenza a (h1n1) 2009,agriflu,fluzo ne,fluzone 2011- 2012 (pf),fluzone 2012- 2013,fluzone pedi 2012- 2013,fluzone high-dose,fluzone 2011- 2012,fluzone high-dose 2011- 12 (pf),fluzone high-dose 2012- 13,fluzone intradermal,fluzo ne intradermal 2012- 2013,fluarix,fluari x 2011- 2012,fluarix 2012- 2013,flucelvax,flu mist,fluvirin,fluviri n 2011- 2012,fluvirin 2012- 2013,physicians ez use flu 2012-
influenza virus vaccine tri- split 2009-2010,influenza virus vaccine tri-split 2010- 2011,influenza virus vaccine tv split 2011-2012 (18 yr & older),influenza virus vaccine tv split 2012-2013 (18 yr & older),influenza virus vaccine trivalent-split 2009-2010/pf,influenza virus vaccine trivalent-split 2010- 2011/pf,influenza virus vaccine tv split 2011-2012 (9 yr & older)/pf,influenza virus vaccine tv split 2012-2013 (5 yr & older)/pf,influenza virus vaccine tv split 2011-2012 (9 yr & older),influenza virus vaccine tv split 2012-2013 (5 yr & older),influenza a (h1n1) virus vaccine monovalent 2009/pf,influenza a (h1n1) virus vaccine monovalent 2009,influenza virus vaccine tv-sp 2011-12 (36 mos and older)/pf,influenza virus vaccine tvs 2012-2013 (36 mos and older)/pf,influenza virus vaccine 2011-2012 (6 mos-35 mos)/pf,influenza virus vaccine 2012-2013 (6 mos-35 mos)/pf,influenza virus vaccine tv split 2011- 2012 (6 mos and older),influenza virus vaccine trivalent-split 2011- 2012/pf,influenza virus vaccine tv split 2012 2013
ADD UM: QUANTITY 1 / 270 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 32 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
13,fluzone quad mos and older),influenza 2013- virus vaccine trivalent-split2014,fluzone 2012-2013quad pedi 2013- (65yr+)/pf,influenza virus2014,single use vaccine tvs 2012-2013 (18ez flu 2012- yrs-64 yrs)/pf,influenza virus2013,fluzone vaccine tv split 2011-2012 (32013- yr & older)/pf,influenza virus2014,fluzone pedi vaccine tv split 2012-2013 (32013- yr & older)/pf,influenza2014,fluzone vaccine tri-splt 2012-13(18high-dose 2013- yr +)cell derived/pf,influenza2014,fluzone virus vaccine trivalent 2009-intradermal 2013- 2010 (live),influenza virus2014,single use vaccine trivalent 2010-2011ez flu 2013- (live),influenza virus vaccine2014,fluarix quad trivalent 2011-20122013-2014,afluria (live),influenza virus vaccine2013- tv live 2012-2013 (2 yrs-492014,fluvirin yrs),influenza-a (h1n1) virus2013- vaccine monovalent 20092014,flulaval (live),influenza virus vaccine2013-2014,fluarix tv split 2011-2012 (4 yr &2013- older)/pf,influenza virus2014,flulaval vaccine tv split 2011-2012 (4quad 2013- yr & older),influenza virus2014,flublok vaccine tv split 2012-2013 (42012- yr & older)/pf,influenza virus2013,flublok vaccine tv split 2012-2013 (42013- yr & older),influenza virus2014,flucelvax vaccine qval live 2013-20142014- (2 yrs-49 yrs),influenza virus2015,fluzone vaccine quad vs 2013-14(36high-dose 2014- mos and older)/pf,influenza2015,flulaval virus vaccine quad vs 2013-quad 2014- 2014 (6 mos-352015,flulaval mos)/pf,influenza virus2014- vaccine tvs 2013-2014 (362015,flublok mos and older)/pf,influenza
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 33 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
2014- virus vaccine tvs 2013-2014 2015,fluzone (6 mos-35 mos)/pf,influenzaquad pedi 2014- virus vaccine tri-split 2013-2015,fluzone 14 (6 mos andintradermal 2014- older),influenza virus2015,fluarix vaccine tvs 2013-2014 (652014-2015,fluarix yr and up)/pf,influenza virusquad 2014- vaccine tvs 2013-2014 (182015,fluzone yrs-64 yrs)/pf,influenza virus2014- vaccine tv split 2013-14 (5 yr2015,fluzone and older)/pf,influenza virusquad 2014- vaccine tv split 2013-2014 (52015,fluvirin yr and older),influenza2014- vaccine tv split 2013-14(182015,flumist quad yr,up) cell2014-2015,afluria derived/pf,influenza virus2014-2015,single vaccine tv split 2013-2014 (4use ez flu 2014- yr and up)/pf,influenza virus2015,fluzone vaccine tv split 2013-2014 (4intraderm quad yr and older),influenza virus2015-16,fluzone vaccine tvs 2013-2014 (362015- mos and older),influenza2016,fluzone virus vaccine quad vs 2013-high-dose 2015- 2014 (36 mos and2016,fluzone older),influenza virusquad 2015- vaccine tv 2012-2013 (18 to2016,fluzone 49 yrs)recomb/pf,influenzaquad pedi 2015- virus vaccine tv 2013-20142016,flulaval (18 to 49quad 2015- yrs)recomb/pf,influenza tv-s2016,afluria 07-08 vaccine,influenza tv-s2015- 08-09 vaccine,influenza tv-s2016,flublok 07-08 vaccine/pf,influenza2015- tv-s 08-092016,flucelvax vaccine/pf,influenza vacc,tri2015- 2007(live),influenza vacc,tri2016,fluvirin 2008(live),influenza vaccine2015-2016,fluarix tv split 2014-15 (18quad 2015- yr,up)cell
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 34 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
2016,flumist quad derived/pf,influenza virus 2015-2016,ez flu vaccine trivalent 2014-20152015-2016 (65 yr,older)/pf,influenza(flucelvax),ez flu virus vaccine quad vs 2014-2015-2016 2015 (36 mos and(fluvirin),fluad older),influenza virus2015- vaccine trival 2014-15 (362016,flulaval mos and older)/pf,influenzaquad 2016- virus vaccine trivalent 2014-2017,afluria 15 (36 mos and2016- older),influenza virus2017,flublok vaccine quadrival 2014-2016-2017,fluarix 15(36 mos,quad 2016- older)/pf,influenza virus2017,flumist quad vaccine tv 2014-2015(182016- yrs,2017,fluvirin older)recomb/pf,influenza2016- virus vaccine quadrival2017,flucelvax 2014-15 (6 mos-35quad 2016- mos)/pf,influenza virus2017,fluzone vaccine trivalent 2014-15high-dose 2016- (18 yrs-64 yrs)/pf,influenza2017,fluzone virus vaccine trivalent 2014-quad 2016- 15 (6 mos and2017,fluzone older),influenza virusquad pedi 2016- vaccine quadrival 2014-2017,fluzone 2015(6 mos andintraderm quad older),influenza virus2016-17,fluad vaccine trivalnt 2014-20152016-2017,ez flu (4 yr, older)/pf,influenza2016-2017 virus vaccine trivalent 2014-(fluvirin),ez flu 2015 (4 yr and2016-2017 older),influenza vaccine(afluria),ez flu 16- quadrivalent live 2014-201517 (fluzon quad (2 yrs-49 yrs),influenza virusped),afluria quad vaccine trivalnt 2014-20152016- (5 yr, older)/pf,influenza2017,fluzone virus vaccine trivalent 2014-high-dose 2017- 2015 (5 yr and
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 35 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
2018,fluzone older),influenza virus quad 2017- vaccine quadrivalent 2015-2018,fluzone 16(18yrs-64yrs)/pf,influenzaquad pedi 2017- virus vaccine trivalent 2015-2018,fluzone 16 (6 mos andintraderm quad older),influenza virus2017-18,fluad vaccine trivalent split 2015-2017- 16(65 yr,up)/pf,influenza2018,fluvirin virus vaccine quadrival2017- split2015-16(362018,flucelvax mos,up)/pf,influenza virusquad 2017- vaccine quadrival 2015-162018,flublok (6 mos-35 mos)/pf,influenza2017- virus vaccine qvalsplit 2015-2018,flublok quad 2016(6 mos and2017-2018,afluria older),influenza virus2017-2018,afluria vaccine quadrival 2015-quad 2017- 2016 (36 mos,2018,flulaval older),influenza virusquad 2017- vaccine trivalnt 2015-20162018,fluarix quad (5 yr, older)/pf,influenza2017- virus vaccine trivalent 2015-2018,flumist quad 2016 (5 yr and2017- older),influenza virus2018,flulaval vaccine tv 2015-2016(18quad 2018- yrs,2019,fluzone older)recomb/pf,influenzaquad 2018- vaccine trivalent 2015-16(182019,fluarix quad yr,up)cell2018- derived/pf,influenza virus2019,flublok quad vaccine trivalent 2015-20162018- (4 yr, older)/pf,influenza2019,fluzone virus vaccine trivalent 2015-quad pedi 2018- 2016 (4 yr and2019,fluzone older),influenza vaccinehigh-dose 2018- quadrivalent live 2015-20162019,afluria (2 yrs-49 yrs),influenza2018-2019,afluria vaccine tvs 2015-16 (65quad 2018- yr,up)/adjuvant
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 36 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
2019,fluad 2018- 2019,flucelvax quad 2018- 2019,flumist quad 2018-2019
mf59c.1/pf,influenza virus vaccine qvalsplit 2016- 2017(6 mos and older),influenza virus vaccine qvalsplit 2016- 2017(6 mos and up)/pf,influenza virus vaccine trivalent 2016-2017 (5 years up)/pf,influenza virus vaccine trivalent 2016- 2017 (5 yr and older),influenza virus vaccine tv 2016-17(18 yrs and older)rcmb/pf,influenza virus vaccine quadval split 2016-17(36 mos up)/pf,influenza vaccine quadrivalent live 2016-2017 (2 yrs-49 yrs),influenza virus vaccine trival 2016-2017 (4yr and older)/pf,influenza virus vaccine trivalent 2016- 2017 (4 yr and older),flu vaccine qs 2016-2017(4 years and older)cell derived/pf,influenza virus vaccine trival split 2016- 2017(65 yr up)/pf,influenza virus vaccine quadrival 2016-17 (6 mos-35 mos)/pf,influenza virus vaccine quadrivalent 2016- 17(18yrs-64yrs)/pf,influenza vaccine tvs 2016-17 (65 yr up)/adjuvant mf59c.1/pf,influenza virus vaccine quadrivalent 2016- 17(18yr and up)/pf,influenza virus vaccine quadrivalent
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 37 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
2016-17(18 year and up),influenza virus vaccine trival split 2017-2018(65 yr up)/pf,influenza virus vaccine quadrivalent 2017- 18 (36 mos up)/pf,influenza virus vaccine quadrival 2017-18 (6 mos-35 mos)/pf,influenza virus vaccine quadrivalent 2017- 18 (6 mos and up),influenza virus vaccine quadrivalent 2017-18(18yrs- 64yrs)/pf,influenza vaccine tvs 2017-18 (65 yr up)/adjuvant mf59c.1/pf,influenza virus vaccine trival 2017-2018 (4yr and older)/pf,influenza virus vaccine trivalent 2017- 2018 (4 yr and older),flu vaccine quad 2017-2018(4 years and older)cell derived/pf,flu vaccine quadriv 2017-2018(4 years and older)cell derived,influenza virus vaccine tv 2017-18(18 yrs and older)rcmb/pf,influenza virus vaccine qv 2017-18(18 yrs and older)rcmb/pf,influenza virus vaccine trivalent 2017-2018 (5 years up)/pf,influenza virus vaccine trivalent 2017- 2018 (5 yr and older),influenza virus vaccine quadrivalent 2017- 18(5 yr and up)/pf,influenza
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 38 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
virus vaccine quadrivalent 2017-18 (5 year and up),influenza virus vaccine qvalsplit 2017-2018(6 mos and up)/pf,influenza vaccine quadrivalent live 2017-2018 (2 yrs-49 yrs),influenza virus vaccine quadrivalent 2018- 19 (6 mos and up),influenza virus vaccine quadrival 2018-2019(6 mos and up)/pf,influenza virus vaccine qv 2018-19(18 yrs and older)rcmb/pf,influenza virus vaccine quadrivalent 2018-19 (36 mos up)/pf,influenza virus vaccine quadrival 2018-19 (6 mos-35 mos)/pf,influenza virus vaccine trival split 2018-2019(65 yr up)/pf,influenza virus vaccine trivalent 2018-2019 (5 years up)/pf,influenza virus vaccine trivalent 2018- 2019 (5 yr and older),influenza virus vaccine quadrivalent 2018- 19(5 yr and up)/pf,influenza virus vaccine quadrivalent 2018-19 (5 year and up),influenza vaccine tvs 2018-19 (65 yr up)/adjuvant mf59c.1/pf,flu vaccine quad 2018-2019(4 years and older)cell derived/pf,flu vaccine quadriv 2018- 2019(4 years and older)cell derived influenza vaccine
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 39 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
quadrivalent live 2018-2019 (2 yrs-49 yrs)
01/01/2016 fish oil omega-3 fatty acids/docosahexanoic acid/epa/fish oil
ADD TO FORMULARY Covered
01/02/2016 calcidol ergocalciferol (vitamin d2) REMOVE FROM FORMULARY
Covered Non-Formulary
01/02/2016 vitamin d,vitamin d3,kids vitamin d3,children's vitamin d
cholecalciferol (vitamin d3) REMOVE UM: CUSTOM
01/02/2016 PEGINTRON peginterferon alfa-2b REMOVE UM: AUTHORIZATION
PA applies
01/02/2016 pacerone amiodarone hcl REMOVE FROM FORMULARY
Covered Non-Formulary
01/02/2016 cordarone,amiod arone hcl,pacerone
amiodarone hcl REMOVE UM: QUANTITY
01/02/2016 pacerone,amioda rone hcl
amiodarone hcl REMOVE UM: QUANTITY
01/02/2016 pacerone,amioda rone hcl
amiodarone hcl REMOVE UM: QUANTITY
01/02/2016 lactulose lactulose CHANGE TIER Covered 01/02/2016 constulose lactulose REMOVE FROM
FORMULARY Covered Non-Formulary
01/03/2016 VITAL-D RX vit b complex no.4/vit d3/ascorbic acid/folic acid/zinc oxid
ADD UM: CUSTOM Covered for CSHCS only
01/26/2016 DELZICOL mesalamine ADD UM: QUANTITY 30 / 30 days 01/27/2016 DELZICOL mesalamine CHANGE UM: QUANTITY 30 / 30 days 6 / 1 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 40 UPDATED 10/2018
March, 2016
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 ORKAMBI,SYMD
EKO lumacaftor/ivacaftor,tezacaft or/ivacaftor
ADD UM: CUSTOM Carveout Drug - Bill MDCH FFS
03/01/2016 levocarnitine,carn itor,carnitor sf,cystadane,sulf zix,xizflus,sod polysulthionate- folic acid,glygest
levocarnitine,levocarnitine (with sugar),betaine,sulfur/sodium sulfate/sodium thiosulf/methyltetrahydrofola te,sulfur/sodium sulfate/sodium thiosulfate/folic acid,fucosyllactose/lacto-n- neotetraose
ADD UM: CUSTOM Carveout Drug - Bill MDCH FFS
03/01/2016 VRAYLAR cariprazine hcl ADD UM: CUSTOM Carveout Drug - Bill MDCH FFS
03/01/2016 SOVALDI sofosbuvir ADD UM: CUSTOM Carveout Drug - Bill MDCH FFS
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 41 UPDATED 10/2018
April, 2016
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/01/2016 asacol
hd,mesalamine mesalamine REMOVE UM: STEP
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 42 UPDATED 10/2018
May, 2016
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/25/2016 vitamin d3 cholecalciferol (vitamin d3) CHANGE TIER Covered 05/25/2016 vitamin
d3,vitamin d cholecalciferol (vitamin d3) ADD UM: QUANTITY 65 / days
05/25/2016 vitamin d3,vitamin d
cholecalciferol (vitamin d3) REMOVE UM: CUSTOM
05/25/2016 vitamin d3,vitamin d
cholecalciferol (vitamin d3) CHANGE UM: AGE At least 65 yrs old
05/25/2016 vitamin d3,vitamin d
cholecalciferol (vitamin d3) REMOVE UM: QUANTITY 65 / days
05/25/2016 vitamin d3,vitamin d
cholecalciferol (vitamin d3) CHANGE TIER Covered
05/25/2016 vitamin d3,vitamin d
cholecalciferol (vitamin d3) REMOVE UM: CUSTOM
05/25/2016 vitamin d3,vitamin d,d3- 2000
cholecalciferol (vitamin d3) REMOVE UM: CUSTOM
05/25/2016 vitamin d3 cholecalciferol (vitamin d3) CHANGE TIER Covered 05/25/2016 vitamin
d3,dialyvite vitamin d
cholecalciferol (vitamin d3) REMOVE UM: CUSTOM
05/25/2016 dialyvite vitamin d cholecalciferol (vitamin d3) REMOVE FROM FORMULARY
Covered Non-Formulary
05/25/2016 vitamin d3 cholecalciferol (vitamin d3) CHANGE TIER Covered 05/25/2016 vitamin d3 cholecalciferol (vitamin d3) CHANGE TIER Covered 05/25/2016 vitamin d3 cholecalciferol (vitamin d3) CHANGE TIER Covered 05/25/2016 kids vitamin d3 cholecalciferol (vitamin d3) REMOVE FROM
FORMULARY Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 43 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
05/25/2016 d-vi-sol,vitamin d3,d-vita,just d,pedia d-vite
cholecalciferol (vitamin d3) REMOVE UM: CUSTOM
05/25/2016 d-vi-sol cholecalciferol (vitamin d3) REMOVE FROM FORMULARY
Covered Non-Formulary
05/25/2016 d-vita cholecalciferol (vitamin d3) REMOVE FROM FORMULARY
Covered Non-Formulary
05/25/2016 JUST D cholecalciferol (vitamin d3) REMOVE FROM FORMULARY
Covered Non-Formulary
05/26/2016 NUPLAZID pimavanserin tartrate ADD UM: CUSTOM Carveout Drug - Bill MDCH FFS
05/26/2016 campral,acampro sate calcium
acamprosate calcium ADD UM: CUSTOM CARVEOUT DRUG - BILL MDCH FFS
05/27/2016 MONONINE,BEN EFIX,PROFILNIN E SD,ALPHANINE SD,RIXUBIS,ALP ROLIX,IXINITY,I DELVION,REBIN YN
factor ix,factor ix human recombinant,factor ix complex human,factor ix recombinant, fc fusion protein,factor ix human recombinant, threonine 148,factor ix recombinant,albumin fusion protein,factor ix (human) recombinant, pegylated
CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 44 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
05/28/2016 butisol sodium,phenobar bital,luminal sodium,phenobar bital sodium,amytal sodium,seconal sodium,pentobar bital sodium,phenobar bital- ns,phenobarbital- 0.9% nacl,nembutal sodium
butabarbital sodium,phenobarbital,pheno barbital sodium,amobarbital sodium,secobarbital sodium,pentobarbital sodium,phenobarbital sodium in 0.9 % sodium chloride
CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 45 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
05/28/2016 halcion,ambien,a mbien cr,edluar,zaleplon ,zolpidem tartrate,lorazepa m,zolpimist,sleep aid,chloral hydrate,sominex, sominex max strength,flurazep am hcl,zolpidem tartrate er,wal- som,sleep ii,nighttime sleep aid,precedex,esta zolam,temazepa m,simply sleep,sleep-eze 3,sleep tabs,ativan,diphe nhydramine hcl,nytol,sleepgel s,sleeping,sleep tablet,fast sleep,nighttime sleep gel,l- tryptophan,alka- seltzer plus allergy,triazolam,l unesta,sonata,zz zquil,midazolam hcl,rest simply,restfully sleep,lydia pinkham herbal,unisom,uni som sleepmelts,uniso m sleep
triazolam,zolpidem tartrate,zaleplon,lorazepam, diphenhydramine hcl,doxylamine succinate,chloral hydrate,flurazepam hcl,dexmedetomidine hcl,estazolam,temazepam,tr yptophan,eszopiclone,midaz olam hcl,ethyl alcohol/herbal drugs,doxepin hcl,quazepam,lorazepam in 0.9 % sodium chloride,dexmedetomidine hcl in 0.9 % sodium chloride,suvorexant
CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 46 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
aid,silenor,medi- sleep,ultra sleep,somnote,re storil,doral,interm ezzo,lorazepam- ns,compoz,sleep- aid,ez nite sleep,nytol quickcaps,quaze pam,wal-sleep z,ormir,sleep time,prosom,dal mane,z- sleep,eszopiclon e,dexmedetomidi ne hcl,nighttime sleep- aid,belsomra,nyt- time sleep,dexmedeto midine-0.9% nacl
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 47 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
05/28/2016 prozac weekly,paxil cr,paxil,zoloft,cital opram hbr,fluvoxamine maleate,fluoxetin e hcl,escitalopram oxalate,paroxetin e hcl,selfemra,sertr aline hcl,paroxetine er,sarafem,lexapr o,celexa,fluoxetin e dr,prozac,st. john's wort,fluvoxamine maleate er,paroxetine cr,luvox cr,pexeva,citalopr am,rapiflux
fluoxetine hcl,paroxetine hcl,sertraline hcl,citalopram hydrobromide,fluvoxamine maleate,escitalopram oxalate,st. john's wort,paroxetine mesylate
CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 48 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
05/28/2016 protriptyline hcl,imipramine pamoate,norpram in,nortriptyline hcl,clomipramine hcl,doxepin hcl,maprotiline hcl,amitriptyline hcl,anafranil,pam elor,tofranil,tofran il-pm,imipramine hcl,amoxapine,de sipramine hcl,trimipramine maleate,surmontil ,vivactil,elavil
protriptyline hcl,imipramine pamoate,desipramine hcl,nortriptyline hcl,clomipramine hcl,doxepin hcl,maprotiline hcl,amitriptyline hcl,imipramine hcl,amoxapine,trimipramine maleate
CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 49 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
05/28/2016 ritalin la,focalin,focalin xr,ritalin,ritalin- sr,dexmethylphen idate hcl,methylphenid ate hcl cd,methylphenida te er,methylin,methy lphenidate hcl,methylin er,methylphenida te sr,concerta,quilliv ant xr,metadate cd,metadate er,daytrana,meth ylphenidate la,dexmethylphen idate hcl er,aptensio xr,quillichew er,methylphenida te hcl er,cotempla xr-odt
methylphenidate hcl,dexmethylphenidate hcl,methylphenidate
CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 50 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
05/28/2016 felbatol,oxcarbaz epine,levetiraceta m,dilantin,zaronti n,neurontin,celon tin,lyrica,dilantin- 125,depacon,dep akote er,depakene,dep akote sprinkle,depakote ,trileptal,tegretol,t egretol xr,lamotrigine,epit ol,carbamazepine ,topiramate,clona zepam,gabapenti n,carbamazepine er,divalproex sodium er,divalproex sodium,levetirace tam er,valproic acid,ethosuximid e,primidone,vimp at,fosphenytoin sodium,valproate sodium,phenytoin sodium,lamictal,l amictal (orange),lamictal (blue),lamictal xr,lamictal xr (blue),lamictal xr (green),lamictal xr (orange),lamictal odt,lamictal odt (orange) lamictal
felbamate,oxcarbazepine,lev etiracetam,phenytoin,ethosu ximide,phenytoin sodium extended,gabapentin,meths uximide,pregabalin,valproic acid (as sodium salt) (valproate sodium),divalproex sodium,valproic acid,carbamazepine,lamotri gine,topiramate,clonazepam,valproate sodium,primidone,lacosamid e,fosphenytoin sodium,phenytoin sodium,ezogabine,zonisami de,tiagabine hcl,mephobarbital,diazepam,rufinamide,vigabatrin,ethoto in,levetiracetam in sodium chloride, iso- osmotic,perampanel,eslicarb azepine acetate,gabapentin/lidocaine hcl/menthol,gabapentin/caps aicin/methyl salicylate/menthol,brivaracet am
CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 51 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
odt (green),potiga,la mictal (green),zonisami de,topiragen,phe nytoin sodium extended,phenyt ek,phenytoin,carb amazepine xr,gabitril,keppra, topamax,zonegra n,klonopin,oxtella r xr,keppra xr,fanatrex,lamotr igine er,felbamate,carb atrol,mysoline,me baral,diastat acudial,tiagabine hcl,banzel,sabril, peganone,levetir acetam- nacl,stavzor,troke ndi xr,cerebyx,meph obarbital,fycompa ,aptiom,qudexy xr,topiramate er,lamotrigine odt,lamotrigine odt (blue),lamotrigine odt (green),lamotrigin e odt (orange),spritam, smartrx gabakit,active- pac,smartrx
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 52 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
gaba-v kit,roweepra,brivi act,vigabatrin,lam otrigine (orange),lamotrigi ne (green),lamotrigin e (blue),roweepra xr,subvenite,subv enite (orange),subvenit e (blue),subvenite (green),vigadrone
05/28/2016 cymbalta,effexor, effexor xr,pristiq,venlafax ine hcl,venlafaxine hcl er,desvenlafaxine er,khedezla,fetzi ma,duloxetine hcl,desvenlafaxin e fumarate er,irenka,desvenl afaxine succinate
duloxetine hcl,venlafaxine hcl,desvenlafaxine succinate,desvenlafaxine,lev omilnacipran hcl,desvenlafaxine fumarate
CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 53 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
05/28/2016 haldol decanoate 50,haldol decanoate 100,haldol,halope ridol lactate,haloperido l,droperidol,halop eridol decanoate,halop eridol decanoate 100,inapsine
haloperidol decanoate,haloperidol lactate,haloperidol,droperido l
CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
05/28/2016 zyprexa,zyprexa zydis,zyprexa relprevv,geodon, saphris,risperidon e,quetiapine fumarate,clozaril,f anapt,clozapine odt,clozapine,ola nzapine,olanzapi ne odt,seroquel,sero quel xr,risperidone odt,ziprasidone hcl,risperdal,faza clo,invega,risperd al consta,risperdal m-tab,invega sustenna,latuda,v ersacloz,invega trinza,paliperidon e er,quetiapine fumarate er
olanzapine,olanzapine pamoate,ziprasidone mesylate,ziprasidone hcl,asenapine maleate,risperidone,quetiapi ne fumarate,clozapine,iloperido ne,paliperidone,risperidone microspheres,paliperidone palmitate,lurasidone hcl
CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
05/28/2016 loxapine,loxitane, adasuve
loxapine succinate,loxapine CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 54 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
05/28/2016 abilify,abilify maintena,abilify discmelt,aripipraz ole,rexulti,aripipra zole dt i t d
aripiprazole,brexpiprazole,ar ipiprazole lauroxil
CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
05/28/2016 strattera,atomoxe tine hcl
atomoxetine hcl CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
05/28/2016 ROZEREM,HETL IOZ
ramelteon,tasimelteon CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
05/28/2016 modafinil,provigil, nuvigil,armodafini l
modafinil,armodafinil CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
05/28/2016 BRINTELLIX,TRI NTELLIX
vortioxetine hydrobromide CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 55 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
05/28/2016 dexedrine,dextro amphetamine- amphet er,dextroampheta mine- amphetamine,me thamphetamine hcl,dextroamphet amine sulfate,dextroam phetamine sulfate er,adderall,proce ntra,vyvanse,add erall xr,amphetamine salt combo,desoxyn,z enzedi,liquadd,de xtrostat,evekeo,d yanavel xr,adzenys xr- odt,mydayis,adze nys er
dextroamphetamine sulfate,dextroamphetamine sulf- saccharate/amphetamine sulf- aspartate,methamphetamine hcl,lisdexamfetamine dimesylate,amphetamine sulfate,amphetamine
CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
05/28/2016 CINRYZE,BERIN ERT,RUCONEST ,HAEGARDA
c1 esterase inhibitor,c1 esterase inhibitor, recombinant
CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
05/28/2016 ILARIS canakinumab/pf CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
05/28/2016 MEKINIST,COTE LLIC,MEKTOVI
trametinib dimethyl sulfoxide,cobimetinib fumarate,binimetinib
CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
05/28/2016 DAKLINZA daclatasvir dihydrochloride CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
05/28/2016 HARVONI,EPCL USA
ledipasvir/sofosbuvir,sofosb uvir/velpatasvir
CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 56 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
05/28/2016 VIEKIRA PAK,VIEKIRA XR
ombitasvir/paritaprevir/ritona vir/dasabuvir sodium
CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
05/28/2016 TECHNIVIE,ZEP ATIER,MAVYRE T
ombitasvir/paritaprevir/ritona vir,elbasvir/grazoprevir,gleca previr/pibrentasvir
CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
05/28/2016 copegus,pegasys ,pegasys proclick,rebetol,p egintron,pegintro n redipen,ribavirin,r ibatab,ribapak,rib asphere,ribasphe re ribapak,infergen, moderiba
ribavirin,peginterferon alfa- 2a,peginterferon alfa- 2b,interferon alfacon-1
CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
05/28/2016 viread,tenofovir disoproxil fumarate
tenofovir disoproxil fumarate CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
05/28/2016 zerit,zidovudine,v idex,videx ec,retrovir,epivir,z iagen,abacavir,st avudine,didanosi ne,emtriva,lamivu dine
stavudine,zidovudine,didano sine,lamivudine,abacavir sulfate,emtricitabine
CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
05/28/2016 nevirapine,sustiv a,viramune,viram une xr,rescriptor,intel ence,edurant,nev irapine er,efavirenz
nevirapine,efavirenz,delavird ine mesylate,etravirine,rilpivirine hcl
CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 57 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
05/28/2016 lamivudine- zidovudine,combi vir,trizivir,epzicom ,abacavir- lamivudine- zidovudine,abaca vir-lamivudine
lamivudine/zidovudine,abac avir sulfate/lamivudine/zidovudin e,abacavir sulfate/lamivudine
CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
05/28/2016 kaletra,lopinavir- ritonavir
lopinavir/ritonavir CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
05/28/2016 ATRIPLA,COMP LERA,ODEFSEY ,SYMFI LO,SYMFI
efavirenz/emtricitabine/tenof ovir disoproxil fumarate,emtricitabine/rilpivi rine hcl/tenofovir disoproxil fumarate,emtricitabine/rilpivi rine hcl/tenofovir alafenamide fumarate,efavirenz/lamivudi ne/tenofovir disoproxil fumarate
CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
05/28/2016 SELZENTRY maraviroc CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
05/28/2016 ISENTRESS,TIVI CAY,VITEKTA,IS ENTRESS HD
raltegravir potassium,dolutegravir sodium,elvitegravir
CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
05/28/2016 STRIBILD,GENV OYA,BIKTARVY
elvitegravir/cobicistat/emtrici tabine/tenofovir disoproxil,elvitegravir/cobicis tat/emtricitabine/tenofovir alafenamide,bictegravir sodium/emtricitabine/tenofov ir alafenamide fumar
CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
05/28/2016 buprenorphine hcl,buprenex,sub utex,belbuca,pro buphine
buprenorphine hcl CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 58 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
05/28/2016 naltrexone hcl,depade,revia
naltrexone hcl CHANGE UM: CUSTOM Carveout - Bill MDCH FFS
05/28/2016 buprenorphine- naloxone,suboxo ne,zubsolv,bunav ail
buprenorphine hcl/naloxone hcl
CHANGE UM: CUSTOM Carveout - Bill MDCH FFS
05/28/2016 VIVITROL naltrexone microspheres ADD UM: CUSTOM Carveout Drug - Bill MDCH FFS
05/28/2016 disulfiram,antabu se
disulfiram CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
05/29/2016 ammonia aromatic,dopram, ammonia inhalant,doxapra m hcl,amoply
ammonia,doxapram hcl CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
05/29/2016 buprenorphine hcl,buprenex,sub utex,belbuca,pro buphine
buprenorphine hcl REMOVE UM: CUSTOM Carveout Drug - Bill MDCH FFS
05/29/2016 BUPRENEX buprenorphine hcl ADD UM: CUSTOM CARVEOUT DRUG - BILL MDCH FFS
05/29/2016 buprenorphine hcl
buprenorphine hcl ADD UM: CUSTOM CARVEOUT DRUG - BILL MDCH FFS
05/29/2016 buprenorphine hcl,subutex
buprenorphine hcl ADD UM: CUSTOM CARVEOUT DRUG - BILL MDCH FFS
05/29/2016 buprenorphine hcl
buprenorphine hcl ADD UM: CUSTOM CARVEOUT DRUG - BILL MDCH FFS
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 59 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
05/29/2016 buprenorphine hcl,subutex
buprenorphine hcl ADD UM: CUSTOM CARVEOUT DRUG - BILL MDCH FFS
05/29/2016 disulfiram,antabu se
disulfiram REMOVE UM: CUSTOM Carveout Drug - Bill MDCH FFS
05/29/2016 disulfiram,antabu se
disulfiram CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
CARVEOUT DRUG - BILL MDCH FFS
05/29/2016 disulfiram,antabu se
disulfiram CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
CARVEOUT DRUG - BILL MDCH FFS
05/29/2016 naltrexone hcl,depade,revia
naltrexone hcl REMOVE UM: CUSTOM Carveout - Bill MDCH FFS
05/29/2016 naltrexone hcl,depade,revia
naltrexone hcl CHANGE UM: CUSTOM Carveout - Bill MDCH FFS
CARVEOUT DRUG - BILL MDCH FFS
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 60 UPDATED 10/2018
June, 2016
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/01/2016 NICOTROL NS nicotine CHANGE UM: QUANTITY 0.333 / Day .334 / 1 days 06/01/2016 latanoprost latanoprost CHANGE UM: QUANTITY 0.083 / day 2.5 / 30 days 06/01/2016 XALATAN latanoprost REMOVE UM: QUANTITY 0.083 / day
06/01/2016 LANTUS SOLOSTAR
insulin glargine,human recombinant analog,insulin glargine, human recombinant analog
REMOVE UM: AGE 0 to 21 yrs old
06/01/2016 fluticasone propionate,flonas e
fluticasone propionate CHANGE UM: QUANTITY 0.533 / day 0.056 / days
06/01/2016 stool softener,sof- lax,docusate sodium,dulcolax stool softener,doc-q- lace,docusoft s,dok,docu soft,col- rite,phillips' laxative,womens stool softener,colace,d ss,docusil,dulcoe ase,correctol extra gentle,genasoft,u ni-ease,woman's laxative-docusate sod
docusate sodium ADD UM: QUANTITY 1 / days
06/01/2016 DULERA mometasone furoate/formoterol fumarate
CHANGE UM: QUANTITY .433 / 1 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 61 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 mevacor,lovastati n,altoprev
lovastatin REMOVE UM: AGE
06/01/2016 colyte with flavor packets,gavilyte- c,peg 3350- electrolyte
peg 3350/sod sulf/sod bicarb/sod chloride/potassium chloride,peg 3350/sod sulf/sod bicarbonate/sod chloride/potassium chl
CHANGE UM: QUANTITY 10.959 / day 134 / 1 days
06/01/2016 peg-3350 and electrolytes,gavily te-g,golytely
peg 3350/sod sulf/sod bicarb/sod chloride/potassium chloride
CHANGE UM: QUANTITY 10.959 / day 134 / 1 days
06/01/2016 peg-3350 with flavor packs,gavilyte- n,nulytely with flavor packs,nulytely,tril yte with flavor packets,peg 3350-electrolyte
sodium chloride/sodium bicarbonate/potassium chloride/peg
CHANGE UM: QUANTITY 10.959 / day 134 / 1 days
06/01/2016 auvi- q,epinephrine,epi pen,epipen 2- pak,adrenaclick
epinephrine REMOVE UM: QUANTITY
06/01/2016 epinephrine epinephrine CHANGE UM: QUANTITY 0.02 / Day .667 / 1 days 06/01/2016 EPIPEN JR 2-
PAK epinephrine CHANGE UM: QUANTITY 0.02 / Day .667 / 1 days
06/01/2016 EPIPEN 2-PAK epinephrine CHANGE UM: QUANTITY 0.02 / day .667 / 1 days 06/01/2016 ADRENACLICK epinephrine REMOVE UM: QUANTITY 0.02 / day
06/01/2016 metformin hcl metformin hcl CHANGE UM: QUANTITY 4 / 1 days 06/01/2016 metformin hcl metformin hcl CHANGE TIER Covered 06/01/2016 metformin hcl metformin hcl CHANGE TIER Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 62 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 metformin hcl er metformin hcl CHANGE TIER Covered 06/01/2016 metformin hcl er metformin hcl CHANGE TIER Covered 06/01/2016 butalb-caff-
acetaminoph- codein
butalbital/acetaminophen/caf feine/codeine phosphate
CHANGE UM: QUANTITY 4 / Day 8 / 1 days
06/01/2016 butalb-caff- acetaminoph- codein
butalbital/acetaminophen/caf feine/codeine phosphate
CHANGE UM: QUANTITY 4 / Day 8 / Day
06/01/2016 fiorinal with codeine #3,ascomp with codeine,butalbital compound- codeine,asa- butalb-caffeine- codeine
codeine phosphate/butalbital/aspirin/ caffeine
CHANGE UM: QUANTITY 4 / Day 8 / Day
06/01/2016 hydrocodone- acetaminophen
hydrocodone bitartrate/acetaminophen
ADD UM: QUANTITY 8 / Day
06/01/2016 hydrocodone- acetaminophen,lo rtab,lorcet plus,norco
hydrocodone bitartrate/acetaminophen
CHANGE UM: QUANTITY 4 / Day 8 / Day
06/01/2016 hydrocodone- acetaminophen
hydrocodone bitartrate/acetaminophen
ADD UM: QUANTITY 8 / Day
06/01/2016 norco,hydrocodo ne- acetaminophen,lo rtab,lorcet
hydrocodone bitartrate/acetaminophen
CHANGE UM: QUANTITY 4 / Day 8 / Day
06/01/2016 hydrocodone- acetaminophen
hydrocodone bitartrate/acetaminophen
ADD UM: QUANTITY 8 / Day
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 63 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 hydrocodone- acetaminophen,lo rtab,norco,lorcet hd
hydrocodone bitartrate/acetaminophen
CHANGE UM: QUANTITY 4 / Day 8 / Day
06/01/2016 dilaudid,hydromo rphone hcl
hydromorphone hcl CHANGE UM: QUANTITY 4 / Day 8 / Day
06/01/2016 dilaudid,hydromo rphone hcl
hydromorphone hcl CHANGE UM: QUANTITY 4 / Day 8 / Day
06/01/2016 hydromorphone hcl,dilaudid
hydromorphone hcl CHANGE UM: QUANTITY 4 / Day 8 / Day
06/01/2016 methadone hcl,methadose,do lophine hcl
methadone hcl CHANGE UM: QUANTITY 4 / Day 8 / Day
06/01/2016 methadone hcl,dolophine hcl
methadone hcl CHANGE UM: QUANTITY 4 / Day 8 / Day
06/01/2016 morphine sulfate morphine sulfate CHANGE UM: QUANTITY 4 / Day 8 / Day 06/01/2016 morphine sulfate morphine sulfate CHANGE UM: QUANTITY 4 / Day 8 / Day 06/01/2016 PERCOCET oxycodone
hcl/acetaminophen ADD UM: QUANTITY 8 / Day
06/01/2016 oxycodone- acetaminophen,e ndocet
oxycodone hcl/acetaminophen
CHANGE UM: QUANTITY 4 / Day 8 / Day
06/01/2016 oxycodone hcl,roxicodone
oxycodone hcl CHANGE UM: QUANTITY 4 / Day 8 / Day
06/01/2016 oxycodone- acetaminophen
oxycodone hcl/acetaminophen
ADD UM: QUANTITY 8 / Day
06/01/2016 oxycodone- acetaminophen,e ndocet,percocet
oxycodone hcl/acetaminophen
CHANGE UM: QUANTITY 4 / Day 8 / Day
06/01/2016 oxycodone- acetaminophen
oxycodone hcl/acetaminophen
ADD UM: QUANTITY 8 / Day
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 64 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 endocet,oxycodo ne- acetaminophen,r oxicet,percocet
oxycodone hcl/acetaminophen
CHANGE UM: QUANTITY 4 / Day 8 / Day
06/01/2016 acetaminophen- codeine
acetaminophen with codeine phosphate
CHANGE UM: QUANTITY 6 / Day 8 / Day
06/01/2016 acetaminophen- codeine,tylenol-
d i 3
acetaminophen with codeine phosphate
CHANGE UM: QUANTITY 6 / Day 8 / Day
06/01/2016 acetaminophen- codeine,tylenol-
d i 4
acetaminophen with codeine phosphate
CHANGE UM: QUANTITY 6 / Day 8 / Day
06/01/2016 alendronate sodium
alendronate sodium CHANGE UM: QUANTITY 0.133 / day 1 / 1 days
06/01/2016 alendronate sodium
alendronate sodium CHANGE UM: QUANTITY 0.133 / day 1 / 1 days
06/01/2016 alendronate sodium
alendronate sodium CHANGE UM: QUANTITY 0.133 / day 1 / 1 days
06/01/2016 alendronate sodium
alendronate sodium CHANGE UM: QUANTITY 0.133 / day .134 / 1 days
06/01/2016 alendronate sodium
alendronate sodium CHANGE UM: QUANTITY 0.133 / day .134 / 1 days
06/01/2016 NOVOLOG FLEXPEN
insulin aspart REMOVE UM: AGE 0 to 21 yrs old
06/01/2016 NOVOLOG MIX 70-30 FLEXPEN,NOVO LOG MIX 70-30
insulin aspart protamine human/insulin aspart
REMOVE UM: AGE 0 to 21 yrs old
06/01/2016 HUMALOG MIX 75-25,HUMALOG MIX 75-25 KWIKPEN
insulin lispro protamine & insulin lispro,insulin lispro protamine and insulin lispro
REMOVE UM: AGE 0 to 21 yrs old
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 65 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 HUMALOG MIX 50-50,HUMALOG MIX 50-50 KWIKPEN
insulin lispro protamine & insulin lispro,insulin lispro protamine and insulin lispro
ADD UM: QUANTITY .667 / 1 days
06/01/2016 HUMALOG MIX 50-50,HUMALOG MIX 50-50 KWIKPEN
insulin lispro protamine & insulin lispro,insulin lispro protamine and insulin lispro
REMOVE UM: AGE 0 to 21 yrs old
06/01/2016 HUMALOG,HUM ALOG KWIKPEN U-100
insulin lispro REMOVE UM: AGE 0 to 21 yrs old
06/01/2016 HUMULIN 70- 30,NOVOLIN 70- 30 INNOLET,HUMU LIN 70/30 KWIKPEN
insulin nph human isophane/insulin regular, human,nph, human insulin isophane/insulin regular, human
REMOVE UM: AGE Up to 21 yrs old
06/01/2016 HUMULIN N,NOVOLIN N INNOLET,HUMU LIN N KWIKPEN
insulin nph human isophane,nph, human insulin isophane
REMOVE UM: AGE Up to 21 yrs old
06/01/2016 nystatin nystatin CHANGE UM: QUANTITY 1 / Day 40 / 1 days 06/01/2016 DOK docusate sodium REMOVE FROM
FORMULARY Non-Formulary
06/01/2016 DOK docusate sodium REMOVE FROM FORMULARY
Non-Formulary
06/01/2016 AVONEX interferon beta-1a/albumin human
REMOVE UM: AUTHORIZATION
PA applies
06/01/2016 estradiol,climara estradiol CHANGE UM: QUANTITY .143 / 1 days 06/01/2016 estradiol,climara,
estradiol transdermal patch
estradiol CHANGE UM: QUANTITY 0.154 / day .143 / 1 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 66 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 estradiol,climara estradiol CHANGE UM: QUANTITY 0.154 / day .154 / 1 days 06/01/2016 estradiol,climara,
estradiol transdermal patch
estradiol CHANGE UM: QUANTITY 0.154 / day .143 / 1 days
06/01/2016 estradiol,climara estradiol CHANGE UM: QUANTITY 0.133 / day .143 / 1 days 06/01/2016 vivelle-
dot,estraderm,alo ra,vivelle,minivell e,estradiol
estradiol CHANGE UM: QUANTITY .286 / 1 days
06/01/2016 vivelle- dot,minivelle,estr adiol
estradiol CHANGE UM: QUANTITY .286 / 1 days
06/01/2016 vivelle- dot,estradiol,alor a,minivelle
estradiol CHANGE UM: QUANTITY .286 / 1 days
06/01/2016 vivelle- dot,estraderm,alo ra,vivelle,minivell e,estradiol
estradiol CHANGE UM: QUANTITY .286 / 1 days
06/01/2016 vivelle- dot,alora,minivell e,estradiol
estradiol CHANGE UM: QUANTITY .286 / 1 days
06/01/2016 ddavp,desmopre ssin acetate
desmopressin acetate CHANGE UM: QUANTITY 1 / Day 6 / 1 days
06/01/2016 ddavp,desmopre ssin acetate
desmopressin acetate (non- refrigerated),desmopressin acetate
REMOVE UM: AUTHORIZATION
06/01/2016 ddavp,desmopre ssin acetate
desmopressin acetate CHANGE UM: QUANTITY 1 / Day 6 / 1 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 67 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 chlorhexidine gluconate,periog ard,peridex,paroe x,perisol
chlorhexidine gluconate CHANGE UM: QUANTITY 1 / Day 16 / 1 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 68 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 children's tylenol,tylenol,inf ants' tylenol,children's pain relief,children's pain-fever,infants' pain- fever,children's non- aspirin,children's q- pap,mapap,infant s' mapap,children's pain reliever,infants' pain reliever,acetamin ophen,children's acetaminophen,f ever reducer-pain reliever,non- aspirin,infant fever-pain reliever,childrens suspension,pedia care fever reducer,infant's pain relief,infants' pain relief,infant pain-fever,child's accudial acetaminophen,in fant pain relief,children's medi- tabs,betatemp,littl e remedies fever-
acetaminophen CHANGE UM: QUANTITY 20 / 1 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 69 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
pain,nortemp
06/01/2016 acetaminophen, mapap
acetaminophen CHANGE UM: QUANTITY 125 / days 20 / 1 days
06/01/2016 microchamber inhaler, assist devices ADD TO FORMULARY Covered 06/01/2016 easivent inhaler, assist devices,
accessories ADD TO FORMULARY Covered
06/01/2016 aerotrach plus inhaler, assist devices ADD TO FORMULARY Covered 06/01/2016 aerochamber mv inhaler, assist devices ADD TO FORMULARY Covered 06/01/2016 easivent inhaler, assist devices,
accessories ADD TO FORMULARY Covered
06/01/2016 e-z spacer inhaler, assist devices ADD TO FORMULARY Covered 06/01/2016 aerochamber
with flowsignal inhaler, assist devices ADD TO FORMULARY Covered
06/01/2016 ace aerosol cloud enhancer
inhaler, assist devices ADD TO FORMULARY Covered
06/01/2016 easivent inhaler, assist devices, accessories
ADD TO FORMULARY Covered
06/01/2016 panda mask inhaler, assist devices, accessories
ADD TO FORMULARY Covered
06/01/2016 mouthpiece inhaler, assist devices, accessories
ADD TO FORMULARY Covered
06/01/2016 pediatric panda mask
inhaler, assist devices, accessories
ADD TO FORMULARY Covered
06/01/2016 pocket chamber inhaler, assist devices ADD TO FORMULARY Covered 06/01/2016 pediatric mask inhaler, assist devices,
accessories ADD TO FORMULARY Covered
06/01/2016 pediatric mask inhaler, assist devices, accessories
ADD TO FORMULARY Covered
06/01/2016 microspacer inhaler, assist devices ADD TO FORMULARY Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 70 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 optichamber inhaler, assist devices, accessories
ADD TO FORMULARY Covered
06/01/2016 one way mouthpiece
inhaler, assist devices, accessories
ADD TO FORMULARY Covered
06/01/2016 breatherite spacer-infant mask,breatherite spacer-neonate msk,breatherite,b reatherite spacer- sm chld msk,breatherite spacer-lg chld msk,breatherite spacer-adult mask
inhaler,assist device with small mask,inhaler, assist devices,inhaler,assist device with medium mask,inhaler,assist device with large mask
ADD TO FORMULARY Covered
06/01/2016 breathrite inhaler, assist devices ADD TO FORMULARY Covered 06/01/2016 breathrite inhaler, assist devices ADD TO FORMULARY Covered 06/01/2016 silicone mask inhaler, assist devices,
accessories ADD TO FORMULARY Covered
06/01/2016 silicone mask inhaler, assist devices, accessories
ADD TO FORMULARY Covered
06/01/2016 easivent inhaler, assist devices ADD TO FORMULARY Covered 06/01/2016 aerochamber z-
stat plus,aerochambe r plus z stat
inhaler,assist device with medium mask
ADD TO FORMULARY Covered
06/01/2016 aerochamber z- stat plus
inhaler, assist devices ADD TO FORMULARY Covered
06/01/2016 aerochamber plus z stat,aerochamber z-stat plus
inhaler,assist device with small mask
ADD TO FORMULARY Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 71 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 aerochamber z- stat plus,aerochambe r plus z stat
inhaler, assist devices ADD TO FORMULARY Covered
06/01/2016 aerochamber z- stat plus,aerochambe r plus z stat
inhaler,assist device with large mask
ADD TO FORMULARY Covered
06/01/2016 primeaire inhaler, assist devices ADD TO FORMULARY Covered 06/01/2016 riteflo inhaler, assist devices ADD TO FORMULARY Covered 06/01/2016 sidestream
mask,sidestream pediatric
inhaler, assist devices, accessories
ADD TO FORMULARY Covered
06/01/2016 watchhaler inhaler, assist devices ADD TO FORMULARY Covered 06/01/2016 liteaire inhaler, assist devices ADD TO FORMULARY Covered 06/01/2016 vortex inhaler, assist devices ADD TO FORMULARY Covered 06/01/2016 prochamber inhaler, assist devices ADD TO FORMULARY Covered 06/01/2016 aerochamber
plus flow-vu inhaler, assist devices ADD TO FORMULARY Covered
06/01/2016 aerochamber mini
inhaler, assist devices ADD TO FORMULARY Covered
06/01/2016 monaghan z stat inhaler, assist devices ADD TO FORMULARY Covered 06/01/2016 monaghan z stat inhaler,assist device with
small mask ADD TO FORMULARY Covered
06/01/2016 monaghan z stat inhaler,assist device with medium mask
ADD TO FORMULARY Covered
06/01/2016 monaghan z stat inhaler,assist device with large mask
ADD TO FORMULARY Covered
06/01/2016 vortex vhc frog mask
inhaler,assist device with medium mask
ADD TO FORMULARY Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 72 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 vortex vhc ladybug mask
inhaler,assist device with small mask
ADD TO FORMULARY Covered
06/01/2016 vortex ladybug mask
inhaler, assist devices, accessories
ADD TO FORMULARY Covered
06/01/2016 vortex frog mask inhaler, assist devices, accessories
ADD TO FORMULARY Covered
06/01/2016 nessi spacer inhaler, assist devices ADD TO FORMULARY Covered 06/01/2016 optichamber
diamond inhaler, assist devices ADD TO FORMULARY Covered
06/01/2016 optichamber diamond
inhaler,assist device with small mask
ADD TO FORMULARY Covered
06/01/2016 optichamber diamond
inhaler,assist device with medium mask
ADD TO FORMULARY Covered
06/01/2016 optichamber diamond
inhaler,assist device with large mask
ADD TO FORMULARY Covered
06/01/2016 litetouch inhaler, assist devices, accessories
ADD TO FORMULARY Covered
06/01/2016 litetouch inhaler, assist devices, accessories
ADD TO FORMULARY Covered
06/01/2016 litetouch inhaler, assist devices, accessories
ADD TO FORMULARY Covered
06/01/2016 vortex inhaler, assist devices, accessories
ADD TO FORMULARY Covered
06/01/2016 aerochamber plus flow-vu
inhaler,assist device with small mask
ADD TO FORMULARY Covered
06/01/2016 aerochamber plus flow-vu
inhaler,assist device with medium mask
ADD TO FORMULARY Covered
06/01/2016 aerochamber plus flow-vu
inhaler,assist device with large mask
ADD TO FORMULARY Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 73 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 compact space chamber plus
inhaler, assist devices ADD TO FORMULARY Covered
06/01/2016 space chamber plus
inhaler, assist devices ADD TO FORMULARY Covered
06/01/2016 inspirachamber inhaler,assist device with small mask
ADD TO FORMULARY Covered
06/01/2016 inspirachamber inhaler,assist device with medium mask
ADD TO FORMULARY Covered
06/01/2016 inspirachamber inhaler, assist devices ADD TO FORMULARY Covered 06/01/2016 flexichamber inhaler, assist devices ADD TO FORMULARY Covered 06/01/2016 aerovent plus inhaler, assist devices ADD TO FORMULARY Covered 06/01/2016 inspirachamber inhaler,assist device with
large mask ADD TO FORMULARY Covered
06/01/2016 soma,carisoprod ol
carisoprodol REMOVE FROM FORMULARY
Covered Non-Formulary
06/01/2016 diltiazem hcl diltiazem hcl CHANGE UM: QUANTITY 1 / Day 3 / 1 days 06/01/2016 diltiazem hcl diltiazem hcl CHANGE UM: QUANTITY 1 / Day 3 / 1 days 06/01/2016 diltiazem hcl diltiazem hcl CHANGE UM: QUANTITY 1 / Day 3 / 1 days 06/01/2016 diltiazem hcl diltiazem hcl CHANGE UM: QUANTITY 4 / Day 3 / 1 days 06/01/2016 metformin hcl metformin hcl CHANGE UM: QUANTITY 4 / 1 days 06/01/2016 metformin hcl metformin hcl CHANGE UM: QUANTITY 4 / 1 days 06/01/2016 acetaminophen-
codeine acetaminophen with codeine phosphate
CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative MED 200mg/day
06/01/2016 acetaminophen- codeine
acetaminophen with codeine phosphate
CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative MED 200mg/day
06/01/2016 acetaminophen- codeine
acetaminophen with codeine phosphate
CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative MED 200mg/day
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 74 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 DURAGESIC fentanyl ADD UM: CUSTOM Cumulative MED 200mg/day
06/01/2016 fentanyl fentanyl CHANGE UM: CUSTOM 200Mg/Day Cumulative Edit
Cumulative MED 200mg/day
06/01/2016 fentanyl fentanyl CHANGE UM: CUSTOM 200Mg/Day Cumulative Edit
Cumulative MED 200mg/day
06/01/2016 fentanyl fentanyl CHANGE UM: CUSTOM 200Mg/Day Cumulative Edit
Cumulative MED 200mg/day
06/01/2016 fentanyl fentanyl CHANGE UM: CUSTOM 200Mg/Day Cumulative Edit
Cumulative MED 200mg/day
06/01/2016 fentanyl fentanyl CHANGE UM: CUSTOM 200Mg/Day Cumulative Edit
Cumulative MED 200mg/day
06/01/2016 hydrocodone- acetaminophen
hydrocodone bitartrate/acetaminophen,hy drocodone bit/acetaminophen
CHANGE UM: CUSTOM Cumulative APAP 4gm/day & MED 200mg/day
06/01/2016 hydrocodone- acetaminophen
hydrocodone bitartrate/acetaminophen,hy drocodone bit/acetaminophen
CHANGE UM: CUSTOM Cumulative APAP 4gm/day & MED 200mg/day
06/01/2016 hydrocodone- acetaminophen
hydrocodone bitartrate/acetaminophen,hy drocodone bit/acetaminophen
CHANGE UM: CUSTOM Cumulative APAP 4gm/day & MED 200mg/day
06/01/2016 hydrocodone- acetaminophen
hydrocodone bitartrate/acetaminophen
CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4gm/day & MED 200mg/day
06/01/2016 hydrocodone- acetaminophen
hydrocodone bitartrate/acetaminophen
CHANGE UM: CUSTOM Max of 4000MG of Apap/day + 200Mg/Day
Cumulative Edit
Cumulative APAP 4gm/day & MED 200mg/day
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 75 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 lorcet hd hydrocodone bitartrate/acetaminophen
CHANGE UM: CUSTOM 200Mg/Day Cumulative Edit
Cumulative APAP 4gm/day & MED 200mg/day
06/01/2016 lorcet hydrocodone bitartrate/acetaminophen
CHANGE UM: CUSTOM 200Mg/Day Cumulative Edit
Cumulative APAP 4gm/day & MED 200mg/day
06/01/2016 lortab hydrocodone bitartrate/acetaminophen
CHANGE UM: CUSTOM 200Mg/Day Cumulative Edit
Cumulative APAP 4gm/day & MED 200mg/day
06/01/2016 lortab hydrocodone bitartrate/acetaminophen
CHANGE UM: CUSTOM 200Mg/Day Cumulative Edit
Cumulative APAP 4gm/day & MED 200mg/day
06/01/2016 lorcet plus hydrocodone bitartrate/acetaminophen
CHANGE UM: CUSTOM 200Mg/Day Cumulative Edit
Cumulative APAP 4gm/day & MED 200mg/day
06/01/2016 hydromorphone hcl
hydromorphone hcl CHANGE UM: CUSTOM 200Mg/Day Cumulative Edit
Cumulative MED 200mg/day
06/01/2016 hydromorphone hcl
hydromorphone hcl CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative MED 200mg/day
06/01/2016 hydromorphone hcl
hydromorphone hcl CHANGE UM: CUSTOM 200Mg/Day Cumulative Edit
Cumulative MED 200mg/day
06/01/2016 hydromorphone hcl
hydromorphone hcl CHANGE UM: CUSTOM 200Mg/Day Cumulative Edit
Cumulative MED 200mg/day
06/01/2016 meperidine hcl meperidine hcl CHANGE UM: CUSTOM 200Mg/Day Cumulative Edit
Cumulative MED 200mg/day
06/01/2016 meperidine hcl meperidine hcl CHANGE UM: CUSTOM 200Mg/Day Cumulative Edit
Cumulative MED 200mg/day
06/01/2016 meperidine hcl meperidine hcl CHANGE UM: CUSTOM 200Mg/Day Cumulative Edit
Cumulative MED 200mg/day
06/01/2016 methadone hcl methadone hcl CHANGE UM: CUSTOM 200Mg/Day Cumulative Edit
Cumulative MED 200mg/day
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 76 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 methadone hcl methadone hcl CHANGE UM: CUSTOM 200Mg/Day Cumulative Edit
Cumulative MED 200mg/day
06/01/2016 methadone intensol
methadone hcl CHANGE UM: CUSTOM 200Mg/Day Cumulative Edit
Cumulative MED 200mg/day
06/01/2016 methadone hcl methadone hcl CHANGE UM: CUSTOM 200Mg/Day Cumulative Edit
Cumulative MED 200mg/day
06/01/2016 methadone hcl methadone hcl CHANGE UM: CUSTOM Cumulative: MED 200mg/day
Cumulative MED 200mg/day
06/01/2016 methadone hcl methadone hcl CHANGE UM: CUSTOM 200Mg/Day Cumulative Edit
Cumulative MED 200mg/day
06/01/2016 morphine sulfate er,morphine sulfate,morphine sulfate cr
morphine sulfate CHANGE UM: CUSTOM 200Mg/Day Cumulative Edit
Cumulative MED 200mg/day
06/01/2016 morphine sulfate er,morphine sulfate,morphine sulfate cr
morphine sulfate CHANGE UM: CUSTOM 200Mg/Day Cumulative Edit
Cumulative MED 200mg/day
06/01/2016 morphine sulfate er,morphine sulfate
morphine sulfate CHANGE UM: CUSTOM Cumulative MED 200mg/day
06/01/2016 morphine sulfate er,morphine sulfate,morphine sulfate cr
morphine sulfate CHANGE UM: CUSTOM 200Mg/Day Cumulative Edit
Cumulative MED 200mg/day
06/01/2016 morphine sulfate morphine sulfate CHANGE UM: CUSTOM 200Mg/Day Cumulative Edit
Cumulative MED 200mg/day
06/01/2016 morphine sulfate morphine sulfate CHANGE UM: CUSTOM 200Mg/Day Cumulative Edit
Cumulative MED 200mg/day
06/01/2016 morphine sulfate morphine sulfate CHANGE UM: CUSTOM 200Mg/Day Cumulative Edit
Cumulative MED 200mg/day
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 77 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 morphine sulfate morphine sulfate CHANGE UM: CUSTOM 200Mg/Day Cumulative Edit
Cumulative MED 200mg/day
06/01/2016 oxycodone hcl oxycodone hcl CHANGE UM: CUSTOM 200Mg/Day Cumulative Edit
Cumulative MED 200mg/day
06/01/2016 endocet oxycodone hcl/acetaminophen
CHANGE UM: CUSTOM Max of 4000MG of Apap/day + 200Mg/Day
Cumulative Edit
Cumulative APAP 4gm/day & MED 200mg/day
06/01/2016 roxicet oxycodone hcl/acetaminophen
CHANGE UM: CUSTOM Max of 4000MG of Apap/day + 200Mg/Day
Cumulative Edit
umulative APAP 4gm/day & MED
200mg/day
06/01/2016 oxycodone- acetaminophen,o xycodone hcl- acetaminophen
oxycodone hcl/acetaminophen
CHANGE UM: CUSTOM umulative APAP 4gm/day & MED
200mg/day
06/01/2016 oxycodone- acetaminophen
oxycodone hcl/acetaminophen
CHANGE TIER Covered
06/01/2016 oxycodone- acetaminophen
oxycodone hcl/acetaminophen
CHANGE UM: QUANTITY 8 / 1 days
06/01/2016 oxycodone- acetaminophen
oxycodone hcl/acetaminophen
CHANGE UM: CUSTOM umulative APAP 4gm/day & MED
200mg/day 06/01/2016 oxycodone hcl oxycodone hcl ADD UM: CUSTOM Cumulative MED
200mg/day 06/01/2016 pentazocine-
naloxone hcl pentazocine hcl/naloxone hcl
ADD UM: CUSTOM Cumulative MED 200mg/day
06/01/2016 tramadol hcl tramadol hcl ADD UM: CUSTOM Cumulative MED 200mg/day
06/01/2016 fentanyl fentanyl REMOVE UM: AUTHORIZATION
PA applies
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 78 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 children's non- aspirin
acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 infants pain
reliever,infant's pain relief
acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 acetaminophen acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 infant's non- aspirin
acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 medi-tabs pain
reliever acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 infant's pain reliever
acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 infant's non-
aspirin acetaminophen CHANGE UM: CUSTOM Cumulative Max
4gm/day acetaminophen
Cumulative APAP 4 gm/day
Edit 06/01/2016 non-aspirin acetaminophen CHANGE UM: CUSTOM Cumulative Max
4gm/day acetaminophen
Cumulative APAP 4 gm/day
Edit 06/01/2016 infant's pain relief acetaminophen CHANGE UM: CUSTOM Cumulative Max
4gm/day acetaminophen
Cumulative APAP 4 gm/day
Edit 06/01/2016 OFIRMEV acetaminophen CHANGE UM: CUSTOM Cumulative Max
4gm/day acetaminophen
Cumulative APAP 4 gm/day
Edit 06/01/2016 ACEPHEN acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 79 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 acetaminophen acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 feverall acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 children's non- aspirin
acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 children's fever
reducer,children's fever reducing
acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 fever
reducer,children's fever reducer
acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 child pain rel-
fever reducer acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 non-aspirin jr strength
acetaminophen CHANGE UM: CUSTOM Cumulative Max 4gm/day
acetaminophen
Cumulative APAP 4 gm/day
Edit 06/01/2016 pain reliever
junior strength acetaminophen CHANGE UM: CUSTOM Cumulative Max
4gm/day acetaminophen
Cumulative APAP 4 gm/day
Edit 06/01/2016 children's non-
aspirin acetaminophen CHANGE UM: CUSTOM Cumulative Max
4gm/day acetaminophen
Cumulative APAP 4 gm/day
Edit 06/01/2016 jr
acetaminophen,a cetaminophen
acetaminophen CHANGE UM: CUSTOM Cumulative Max 4gm/day
acetaminophen
Cumulative APAP 4 gm/day
Edit 06/01/2016 jr. str non-aspirin acetaminophen CHANGE UM: CUSTOM Cumulative Max
4gm/day acetaminophen
Cumulative APAP 4 gm/day
Edit
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 80 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 junior mapap acetaminophen CHANGE UM: CUSTOM Cumulative Max 4gm/day
acetaminophen
Cumulative APAP 4 gm/day
Edit 06/01/2016 junior pain
reliever,jr. strength pain reliever
acetaminophen CHANGE UM: CUSTOM Cumulative Max 4gm/day
acetaminophen
Cumulative APAP 4 gm/day
Edit
06/01/2016 jr. str non-aspirin pain
acetaminophen CHANGE UM: CUSTOM Cumulative Max 4gm/day
acetaminophen
Cumulative APAP 4 gm/day
Edit 06/01/2016 juniors'
acetaminophen acetaminophen ADD UM: CUSTOM Cumulative
APAP 4 gm/day Edit
06/01/2016 jr acetaminophen acetaminophen CHANGE UM: CUSTOM Cumulative Max 4gm/day
acetaminophen
Cumulative APAP 4 gm/day
Edit 06/01/2016 jr pain & fever acetaminophen CHANGE UM: CUSTOM Cumulative Max
4gm/day acetaminophen
Cumulative APAP 4 gm/day
Edit 06/01/2016 non-aspirin acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 acetaminophen acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 children's
acetaminophen acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 children's non- aspirin
acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 81 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 acetaminophen acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 ed-apap acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 children's silapap acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 pain relief acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 q-pap,children's q-pap
acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 children's non-
aspirin acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 mapap acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 children's pain
relief acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 children's pain and fever
acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 acetaminophen acetaminophen ADD UM: CUSTOM Cumulative
APAP 4 gm/day Edit
06/01/2016 acetaminophen acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 82 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 children's medi- tabs
acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 children's q-pap acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 CHILDREN'S TYLENOL
acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 non-aspirin acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 children's pain reliever
acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 children's pain
relief acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 mapap acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 children's non-
aspirin acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 nortemp acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 betatemp acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 children's acetaminophen
acetaminophen ADD UM: CUSTOM Cumulative APAP 4 gm/day
Edit
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 83 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 children's acetaminophen,c hildren's pain- fever,childrens suspension
acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit
06/01/2016 pediacare fever reducer
acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 infant pain
relief,infant pain- fever
acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 infants' pain
relief,infant's pain relief
acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 infant pain-
fever,infants' pain-fever,infants' pain relief,infants' pain reliever
acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit
06/01/2016 children's pain- fever
acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 INFANTS'
TYLENOL acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 fever reducer- pain reliever,infant fever-pain reliever
acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit
06/01/2016 fever reducer- pain reliever
acetaminophen CHANGE UM: CUSTOM Cumulative Max 4gm/day
acetaminophen
Cumulative APAP 4 gm/day
Edit
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 84 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 infants' pain- fever,infant pain- fever
acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 little remedies
fever-pain acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 children's acetaminophen
acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 acetaminophen acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 MAPAP acetaminophen CHANGE UM: CUSTOM Cumulative Max 4gm/day
acetaminophen
Cumulative APAP 4 gm/day
Edit 06/01/2016 acephen acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 feverall acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 acetaminophen acetaminophen ADD UM: CUSTOM Cumulative
APAP 4 gm/day Edit
06/01/2016 acetaminophen,p ain reliever
acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 tactinal acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 pain reliever acetaminophen ADD UM: CUSTOM Cumulative APAP 4 gm/day
Edit
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 85 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 pain reliever acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 non-aspirin pain
relief acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 mapap acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 pain relief acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 TYLENOL acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 non-aspirin acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 medi-tabs acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 athenol acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 masophen acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 pharbetol acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 q-pap acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 86 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 PAIN & FEVER acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 children's
acetaminophen acetaminophen CHANGE UM: CUSTOM Cumulative Max
4gm/day acetaminophen
Cumulative APAP 4 gm/day
Edit 06/01/2016 acetaminophen acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 MAPAP acetaminophen CHANGE UM: CUSTOM Cumulative Max 4gm/day
acetaminophen
Cumulative APAP 4 gm/day
Edit 06/01/2016 non-aspirin extra
strength acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 mapap acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 tylophen acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 pain reliever acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 pain relief acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 mapap acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 pain reliever acetaminophen ADD UM: CUSTOM Cumulative
APAP 4 gm/day Edit
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 87 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 pain reliever acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 acetaminophen
extra strength,acetami nophen
acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit
06/01/2016 masophen acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 medi-tabs extra
strength acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 q-pap extra strength
acetaminophen CHANGE UM: CUSTOM Cumulative Max 4gm/day
acetaminophen
Cumulative APAP 4 gm/day
Edit 06/01/2016 non-aspirin pain
relief,pain relief acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 tactinal acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 acetaminophen acetaminophen ADD UM: CUSTOM Cumulative
APAP 4 gm/day Edit
06/01/2016 acetaminophen,a cetaminophen es,pain reliever
acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 extra strength
non-aspirin,non- aspirin extra strength
acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 88 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 TYLENOL EXTRA STRENGTH
acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 medi-tabs acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 pain reliever acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 pain
relief,acetaminop hen
acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 pain relief,pain
relief extra strength,acetami nophen
acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit
06/01/2016 pharbetol acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 q-pap extra
strength acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 acetaminophen,a cetaminophen pain relief
acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 pain & fever acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 shake that ache acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 89 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 acetaminophen acetaminophen CHANGE UM: CUSTOM Cumulative Max 4gm/day
acetaminophen
Cumulative APAP 4 gm/day
Edit 06/01/2016 TYLENOL SORE
THROAT acetaminophen CHANGE UM: CUSTOM Cumulative Max
4gm/day acetaminophen
Cumulative APAP 4 gm/day
Edit 06/01/2016 non-aspirin extra
strength acetaminophen CHANGE UM: CUSTOM Cumulative Max
4gm/day acetaminophen
Cumulative APAP 4 gm/day
Edit 06/01/2016 mapap acetaminophen CHANGE UM: CUSTOM Cumulative Max
4gm/day acetaminophen
Cumulative APAP 4 gm/day
Edit 06/01/2016 pain relief adult acetaminophen CHANGE UM: CUSTOM Cumulative Max
4gm/day acetaminophen
Cumulative APAP 4 gm/day
Edit 06/01/2016 pain reliever-
fever reducer acetaminophen CHANGE UM: CUSTOM Cumulative Max
4gm/day acetaminophen
Cumulative APAP 4 gm/day
Edit 06/01/2016 MAPAP acetaminophen CHANGE UM: CUSTOM Cumulative Max
4gm/day acetaminophen
Cumulative APAP 4 gm/day
Edit 06/01/2016 acetaminophen acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 feverall acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 acephen acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 90 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 acetaminophen er,acetaminophe n 8 hour,acetaminop hen
acetaminophen CHANGE UM: CUSTOM Cumulative Max 4gm/day
acetaminophen
Cumulative APAP 4 gm/day
Edit
06/01/2016 mapap arthritis pain
acetaminophen CHANGE UM: CUSTOM Cumulative Max 4gm/day
acetaminophen
Cumulative APAP 4 gm/day
Edit 06/01/2016 arthritis pain relief acetaminophen ADD UM: CUSTOM Cumulative
APAP 4 gm/day Edit
06/01/2016 arthritis pain relief,arthritis pain,arthritis pain reliever
acetaminophen CHANGE UM: CUSTOM Cumulative Max 4gm/day
acetaminophen
Cumulative APAP 4 gm/day
Edit
06/01/2016 arthritis pain reliever
acetaminophen CHANGE UM: CUSTOM Cumulative Max 4gm/day
acetaminophen
Cumulative APAP 4 gm/day
Edit 06/01/2016 8 hour pain
reliever,8 hour,8 hour pain relief
acetaminophen CHANGE UM: CUSTOM Cumulative Max 4gm/day
acetaminophen
Cumulative APAP 4 gm/day
Edit 06/01/2016 non-aspirin 8
hour acetaminophen CHANGE UM: CUSTOM Cumulative Max
4gm/day acetaminophen
Cumulative APAP 4 gm/day
Edit 06/01/2016 pain relief,pain
reliever acetaminophen CHANGE UM: CUSTOM Cumulative Max
4gm/day acetaminophen
Cumulative APAP 4 gm/day
Edit 06/01/2016 acetaminophen acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 MAPAP acetaminophen CHANGE UM: CUSTOM Cumulative Max 4gm/day
acetaminophen
Cumulative APAP 4 gm/day
Edit
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 91 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 FEVERALL acetaminophen CHANGE UM: CUSTOM Cumulative Max 4gm/day
acetaminophen
Cumulative APAP 4 gm/day
Edit 06/01/2016 children's tactinal acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 mapap acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 children's non-
aspirin acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 acetaminophen,c hildren's acetaminophen
acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 children's non-
aspirin,non- aspirin
acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 children's pain &
fever acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 children's non- aspirin
acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 non-aspirin acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 children's pain reliever
acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 92 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 childrens acetaminophen,c hildren's acetaminophen
acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit
06/01/2016 acetaminophen acetaminophen CHANGE UM: CUSTOM Cumulative Max 4gm/day
acetaminophen
Cumulative APAP 4 gm/day
Edit 06/01/2016 child non-aspirin acetaminophen CHANGE UM: CUSTOM Cumulative Max
4gm/day acetaminophen
Cumulative APAP 4 gm/day
Edit 06/01/2016 children's mapap acetaminophen CHANGE UM: CUSTOM Cumulative Max
4gm/day acetaminophen
Cumulative APAP 4 gm/day
Edit 06/01/2016 children's pain
reliever,child pain relief
acetaminophen CHANGE UM: CUSTOM Cumulative Max 4gm/day
acetaminophen
Cumulative APAP 4 gm/day
Edit 06/01/2016 children's easy-
melts acetaminophen CHANGE UM: CUSTOM Cumulative Max
4gm/day acetaminophen
Cumulative APAP 4 gm/day
Edit 06/01/2016 children's
acetaminophen acetaminophen ADD UM: CUSTOM Cumulative
APAP 4 gm/day Edit
06/01/2016 children's acetaminophen
acetaminophen CHANGE UM: CUSTOM Cumulative Max 4gm/day
acetaminophen
Cumulative APAP 4 gm/day
Edit 06/01/2016 q-pap acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 nortemp acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 93 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 SILAPAP acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 infant's
acetaminophen acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 acetaminophen acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 infant's non-
aspirin,infants' non-aspirin
acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 infant's pain relief acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 infants' pain reliever,infant's pain reliever
acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 mapap infant acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 children's acetaminophen
acetaminophen CHANGE UM: CUSTOM Cumulative Max 4gm/day
acetaminophen
Cumulative APAP 4 gm/day
Edit 06/01/2016 acetaminophen-
codeine acetaminophen with codeine phosphate
CHANGE UM: CUSTOM Cumulative MED 200mg/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 acetaminophen-
codeine acetaminophen with codeine phosphate
CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 acetaminophen-
codeine acetaminophen with codeine phosphate
CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 94 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 acetaminophen- codeine
acetaminophen with codeine phosphate
CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 acetaminophen-
codeine acetaminophen with codeine phosphate
CHANGE UM: CUSTOM Cumulative MED 200mg/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 acetaminophen-
codeine acetaminophen with codeine phosphate
CHANGE UM: CUSTOM Cumulative MED 200mg/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 butalbital-
acetaminophen- caffe
butalbital/acetaminophen/caf feine
CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 MARGESIC butalbital/acetaminophen/caf
feine CHANGE UM: CUSTOM Cumulative:
4gm/day acetaminophen
Cumulative APAP 4 gm/day
Edit 06/01/2016 ESGIC butalbital/acetaminophen/caf
feine CHANGE UM: CUSTOM Cumulative:
4gm/day acetaminophen
Cumulative APAP 4 gm/day
Edit 06/01/2016 capacet butalbital/acetaminophen/caf
feine CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 ZEBUTAL butalbital/acetaminophen/caf feine
CHANGE UM: CUSTOM Cumulative: 4gm/day
acetaminophen
Cumulative APAP 4 gm/day
Edit 06/01/2016 butalbital-
acetaminophen- caffe
butalbital/acetaminophen/caf feine
CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 fioricet butalbital/acetaminophen/caf
feine CHANGE UM: CUSTOM Cumulative:
4gm/day acetaminophen
Cumulative APAP 4 gm/day
Edit 06/01/2016 ESGIC butalbital/acetaminophen/caf
feine CHANGE UM: CUSTOM Cumulative:
4gm/day acetaminophen
Cumulative APAP 4 gm/day
Edit
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 95 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 butalb-caff- acetaminoph- codein
butalbital/acetaminophen/caf feine/codeine phosphate
CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 butalbital-
acetaminophen,a cetaminophen- butalbital
butalbital/acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit
06/01/2016 MARTEN-TAB butalbital/acetaminophen CHANGE UM: CUSTOM Cumulative: 4gm/day
acetaminophen
Cumulative APAP 4 gm/day
Edit 06/01/2016 tencon butalbital/acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 butalbital-aspirin- caffeine
butalbital/aspirin/caffeine ADD UM: CUSTOM Cumulative APAP 4 gm/day
Edit 06/01/2016 butalbital-aspirin-
caffeine butalbital/aspirin/caffeine CHANGE UM: CUSTOM Max of 4000MG
of Apap/day Cumulative
APAP 4 gm/day Edit
06/01/2016 asa-butalb- caffeine-codeine
codeine phosphate/butalbital/aspirin/ caffeine
CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 ascomp with
codeine codeine phosphate/butalbital/aspirin/ caffeine
CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 butalbital
compound- codeine
codeine phosphate/butalbital/aspirin/ caffeine
CHANGE UM: CUSTOM Max of 4000MG of Apap/day
Cumulative APAP 4 gm/day
Edit 06/01/2016 fentanyl fentanyl CHANGE UM: CUSTOM Cumulative MED
200mg/day Cumulative MED 200mg/day Edit
06/01/2016 fentanyl fentanyl CHANGE UM: CUSTOM Cumulative MED 200mg/day
Cumulative MED 200mg/day Edit
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 96 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 DURAGESIC fentanyl CHANGE UM: CUSTOM Cumulative MED 200mg/day
Cumulative MED 200mg/day Edit
06/01/2016 fentanyl fentanyl CHANGE UM: CUSTOM Cumulative MED 200mg/day
Cumulative MED 200mg/day Edit
06/01/2016 fentanyl fentanyl CHANGE UM: CUSTOM Cumulative MED 200mg/day
Cumulative MED 200mg/day Edit
06/01/2016 fentanyl fentanyl CHANGE UM: CUSTOM Cumulative MED 200mg/day
Cumulative MED 200mg/day Edit
06/01/2016 hydrocodone- acetaminophen
hydrocodone bitartrate/acetaminophen,hy drocodone bit/acetaminophen
CHANGE UM: CUSTOM Cumulative APAP 4gm/day & MED 200mg/day
Cumulative APAP 4gm/day & MED 200mg/day
Edits 06/01/2016 lorcet hd hydrocodone
bitartrate/acetaminophen CHANGE UM: CUSTOM Cumulative
APAP 4gm/day & MED 200mg/day
Cumulative APAP 4gm/day & MED 200mg/day
Edits 06/01/2016 lortab hydrocodone
bitartrate/acetaminophen CHANGE UM: CUSTOM Cumulative
APAP 4gm/day & MED 200mg/day
Cumulative APAP 4gm/day & MED 200mg/day
Edits 06/01/2016 hydrocodone-
acetaminophen hydrocodone bitartrate/acetaminophen
CHANGE UM: CUSTOM Cumulative APAP 4gm/day & MED 200mg/day
Cumulative APAP 4gm/day & MED 200mg/day
Edits 06/01/2016 hydrocodone-
acetaminophen hydrocodone bitartrate/acetaminophen,hy drocodone bit/acetaminophen
CHANGE UM: CUSTOM Cumulative APAP 4gm/day & MED 200mg/day
Cumulative APAP 4gm/day & MED 200mg/day
Edits 06/01/2016 lorcet hydrocodone
bitartrate/acetaminophen CHANGE UM: CUSTOM Cumulative
APAP 4gm/day & MED 200mg/day
Cumulative APAP 4gm/day & MED 200mg/day
Edits
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 97 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 lortab hydrocodone bitartrate/acetaminophen
CHANGE UM: CUSTOM Cumulative APAP 4gm/day & MED 200mg/day
Cumulative APAP 4gm/day & MED 200mg/day
Edits 06/01/2016 hydrocodone-
acetaminophen hydrocodone bitartrate/acetaminophen
CHANGE UM: CUSTOM Cumulative APAP 4gm/day & MED 200mg/day
Cumulative APAP 4gm/day & MED 200mg/day
Edits 06/01/2016 hydrocodone-
acetaminophen hydrocodone bitartrate/acetaminophen,hy drocodone bit/acetaminophen
CHANGE UM: CUSTOM Cumulative APAP 4gm/day & MED 200mg/day
Cumulative APAP 4gm/day & MED 200mg/day
Edits 06/01/2016 lortab hydrocodone
bitartrate/acetaminophen CHANGE UM: CUSTOM 200Mg/Day
Cumulative Edit Cumulative MED 200mg/Day Edit
06/01/2016 lorcet plus hydrocodone bitartrate/acetaminophen
CHANGE UM: CUSTOM Cumulative APAP 4gm/day & MED 200mg/day
Cumulative APAP 4gm/day & MED 200mg/day
Edits 06/01/2016 hydromorphone
hcl hydromorphone hcl CHANGE UM: CUSTOM Cumulative MED
200mg/day Cumulative MED 200mg/day Edit
06/01/2016 DILAUDID hydromorphone hcl CHANGE UM: CUSTOM Cumulative: MED 200mg/day
Cumulative MED 200mg/day Edit
06/01/2016 hydromorphone hcl
hydromorphone hcl CHANGE UM: CUSTOM Cumulative MED 200mg/day
Cumulative MED 200mg/day Edit
06/01/2016 hydromorphone hcl
hydromorphone hcl CHANGE UM: CUSTOM Cumulative MED 200mg/day
Cumulative MED 200mg/day Edit
06/01/2016 DILAUDID hydromorphone hcl CHANGE UM: CUSTOM Cumulative: MED 200mg/day
Cumulative MED 200mg/day Edit
06/01/2016 hydromorphone hcl
hydromorphone hcl CHANGE UM: CUSTOM Cumulative MED 200mg/day
Cumulative MED 200mg/day Edit
06/01/2016 meperidine hcl meperidine hcl CHANGE UM: CUSTOM Cumulative MED 200mg/day
Cumulative MED 200mg/day Edit
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 98 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 meperidine hcl meperidine hcl CHANGE UM: CUSTOM Cumulative MED 200mg/day
Cumulative MED 200mg/day Edit
06/01/2016 meperidine hcl meperidine hcl CHANGE UM: CUSTOM Cumulative MED 200mg/day
Cumulative MED 200mg/day Edit
06/01/2016 methadone hcl methadone hcl CHANGE UM: CUSTOM Cumulative MED 200mg/day
Cumulative MED 200mg/day Edit
06/01/2016 methadone hcl methadone hcl CHANGE UM: CUSTOM Cumulative MED 200mg/day
Cumulative MED 200mg/day Edit
06/01/2016 METHADOSE methadone hcl CHANGE UM: CUSTOM 200Mg/Day Cumulative Edit
Cumulative MED 200mg/day Edit
06/01/2016 methadone intensol
methadone hcl CHANGE UM: CUSTOM Cumulative MED 200mg/day
Cumulative MED 200mg/day Edit
06/01/2016 methadone hcl methadone hcl CHANGE UM: CUSTOM Cumulative MED 200mg/day
Cumulative MED 200mg/day Edit
06/01/2016 methadone hcl methadone hcl CHANGE UM: CUSTOM Cumulative MED 200mg/day
Cumulative MED 200mg/day Edit
06/01/2016 methadone hcl methadone hcl CHANGE UM: CUSTOM 200Mg/Day Cumulative Edit
Cumulative MED 200mg/day Edit
06/01/2016 methadone hcl methadone hcl CHANGE UM: CUSTOM Cumulative MED 200mg/day
Cumulative MED 200mg/day Edit
06/01/2016 morphine sulfate morphine sulfate CHANGE UM: CUSTOM 200Mg/Day Cumulative Edit
Cumulative MED 200mg/day Edit
06/01/2016 morphine sulfate er,morphine sulfate,morphine sulfate cr
morphine sulfate CHANGE UM: CUSTOM Cumulative MED 200mg/day
Cumulative MED 200mg/day Edit
06/01/2016 MS CONTIN morphine sulfate CHANGE UM: CUSTOM Cumulative: MED 200mg/day
Cumulative MED 200mg/day Edit
06/01/2016 morphine sulfate morphine sulfate CHANGE UM: CUSTOM Cumulative MED 200mg/day
Cumulative MED 200mg/day Edit
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 99 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 morphine sulfate morphine sulfate CHANGE UM: CUSTOM Cumulative MED 200mg/day
Cumulative MED 200mg/day Edit
06/01/2016 MS CONTIN morphine sulfate CHANGE UM: CUSTOM Cumulative: MED 200mg/day
Cumulative MED 200mg/day Edit
06/01/2016 morphine sulfate,morphine sulfate er,morphine sulfate cr
morphine sulfate CHANGE UM: CUSTOM Cumulative MED 200mg/day
Cumulative MED 200mg/day Edit
06/01/2016 morphine sulfate morphine sulfate CHANGE UM: CUSTOM Cumulative MED 200mg/day
Cumulative MED 200mg/day Edit
06/01/2016 MS CONTIN morphine sulfate CHANGE UM: CUSTOM Cumulative: MED 200mg/day
Cumulative MED 200mg/day Edit
06/01/2016 morphine sulfate er,morphine sulfate
morphine sulfate CHANGE UM: CUSTOM Cumulative MED 200mg/day
Cumulative MED 200mg/day Edit
06/01/2016 morphine sulfate morphine sulfate CHANGE UM: CUSTOM Cumulative MED 200mg/day
Cumulative MED 200mg/day Edit
06/01/2016 morphine sulfate er,morphine sulfate,morphine sulfate cr
morphine sulfate CHANGE UM: CUSTOM Cumulative MED 200mg/day
Cumulative MED 200mg/day Edit
06/01/2016 morphine sulfate er,morphine sulfate,morphine sulfate cr
morphine sulfate CHANGE UM: CUSTOM 200Mg/Day Cumulative Edit
Cumulative MED 200mg/day Edit
06/01/2016 MS CONTIN morphine sulfate CHANGE UM: CUSTOM Cumulative: MED 200mg/day
Cumulative MED 200mg/day Edit
06/01/2016 oxycodone hcl oxycodone hcl CHANGE UM: CUSTOM Cumulative MED 200mg/day
Cumulative MED 200mg/day Edit
06/01/2016 oxycodone hcl oxycodone hcl CHANGE UM: CUSTOM Cumulative MED 200mg/day
Cumulative MED 200mg/day Edit
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 100 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 oxycodone- acetaminophen,o xycodone hcl- acetaminophen
oxycodone hcl/acetaminophen
CHANGE UM: CUSTOM umulative APAP 4gm/day & MED
200mg/day
Cumulative APAP 4gm/day & MED 200mg/day
Edits 06/01/2016 endocet oxycodone
hcl/acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day + 200Mg/Day
Cumulative Edit
Cumulative APAP 4gm/day & MED 200mg/day
Edits 06/01/2016 endocet oxycodone
hcl/acetaminophen CHANGE UM: CUSTOM Cumulative
APAP 4gm/day & MED 200mg/day
Cumulative APAP 4gm/day & MED 200mg/day
Edits 06/01/2016 roxicet oxycodone
hcl/acetaminophen CHANGE UM: CUSTOM umulative APAP
4gm/day & MED 200mg/day
Cumulative APAP 4gm/day & MED 200mg/day
Edits 06/01/2016 oxycodone-
acetaminophen oxycodone hcl/acetaminophen
ADD UM: CUSTOM Cumulative APAP 4gm/day & MED 200mg/day
Edits 06/01/2016 oxycodone-
acetaminophen oxycodone hcl/acetaminophen
CHANGE UM: CUSTOM Max of 4000MG of Apap/day + 200Mg/Day
Cumulative Edit
Cumulative APAP 4gm/day & MED 200mg/day
Edits 06/01/2016 oxycodone-
acetaminophen oxycodone hcl/acetaminophen
CHANGE UM: CUSTOM umulative APAP 4gm/day & MED
200mg/day
Cumulative APAP 4gm/day & MED 200mg/day
Edits 06/01/2016 endocet oxycodone
hcl/acetaminophen CHANGE UM: CUSTOM Max of 4000MG
of Apap/day + 200Mg/Day
Cumulative Edit
Cumulative APAP 4gm/day & MED 200mg/day
Edits 06/01/2016 pentazocine-
naloxone hcl pentazocine hcl/naloxone hcl
CHANGE UM: CUSTOM Cumulative MED 200mg/day
Cumulative MED 200mg/day Edit
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 101 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 tramadol hcl tramadol hcl CHANGE UM: CUSTOM Cumulative MED 200mg/day
Cumulative MED 200mg/day Edit
06/01/2016 synthroid,levothyr oxine sodium,levothroid ,unithroid,tirosint, pcca t4 sodium dilution,levoxyl
levothyroxine sodium REMOVE UM: AGE
06/01/2016 HUMULIN R insulin regular, human REMOVE UM: CUSTOM 200 units per day
06/01/2016 alendronate sodium
alendronate sodium CHANGE UM: QUANTITY 1 / 1 days 1 / Day
06/01/2016 alendronate sodium
alendronate sodium CHANGE UM: QUANTITY 1 / 1 days 1 / Day
06/01/2016 alendronate sodium
alendronate sodium CHANGE UM: QUANTITY 1 / 1 days 1 / Day
06/01/2016 TECFIDERA dimethyl fumarate CHANGE UM: QUANTITY 0.164 / day 2 / Day 06/01/2016 clopidogrel clopidogrel bisulfate ADD UM: QUANTITY 1 / 30 days 06/01/2016 clopidogrel,plavix clopidogrel bisulfate CHANGE UM: QUANTITY 0.034 / Day 1 / 30 days 06/01/2016 GLUCAGON
EMERGENCY KIT
glucagon,human recombinant
CHANGE UM: QUANTITY 0.034 / Day 1 / 30 days
06/01/2016 PULMICORT FLEXHALER
budesonide CHANGE UM: QUANTITY 0.034 / Day 1 / 30 days
06/01/2016 PULMICORT FLEXHALER
budesonide CHANGE UM: QUANTITY 0.034 / Day 1 / 30 days
06/01/2016 TUDORZA PRESSAIR
aclidinium bromide CHANGE UM: QUANTITY 0.4 / day 1 / 30 days
06/01/2016 omeprazole magnesium
omeprazole magnesium ADD UM: QUANTITY 2 / Day
06/01/2016 omeprazole magnesium
omeprazole magnesium CHANGE UM: QUANTITY 1 / Day 2 / Day
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 102 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 furosemide,lasix furosemide ADD UM: QUANTITY 2 / Day 06/01/2016 furosemide,lasix furosemide CHANGE UM: QUANTITY 1 / Day 2 / Day 06/01/2016 furosemide,lasix furosemide ADD UM: QUANTITY 2 / Day 06/01/2016 furosemide,lasix furosemide CHANGE UM: QUANTITY 1 / Day 2 / Day 06/01/2016 furosemide,lasix furosemide ADD UM: QUANTITY 2 / Day 06/01/2016 lasix,furosemide furosemide CHANGE UM: QUANTITY 1 / Day 2 / Day 06/01/2016 glyburide-
metformin hcl,glucovance
glyburide/metformin hcl CHANGE UM: QUANTITY 1 / Day 2 / Day
06/01/2016 glyburide- metformin hcl,glucovance
glyburide/metformin hcl CHANGE UM: QUANTITY 1 / Day 2 / Day
06/01/2016 orphenadrine citrate
orphenadrine citrate ADD UM: QUANTITY 2 / Day
06/01/2016 orphenadrine citrate
orphenadrine citrate CHANGE UM: QUANTITY 1 / Day 2 / Day
06/01/2016 INVOKAMET canagliflozin/metformin hcl CHANGE UM: QUANTITY 1 / Day 2 / Day 06/01/2016 INVOKAMET canagliflozin/metformin hcl CHANGE UM: QUANTITY 1 / Day 2 / Day 06/01/2016 INVOKAMET canagliflozin/metformin hcl CHANGE UM: QUANTITY 1 / Day 2 / Day 06/01/2016 valacyclovir,valtre
x valacyclovir hcl CHANGE UM: QUANTITY 1 / Day 3 / Day
06/01/2016 pramipexole dihydrochloride,m irapex
pramipexole di-hcl CHANGE UM: QUANTITY 1 / Day 3 / Day
06/01/2016 pramipexole dihydrochloride,m irapex
pramipexole di-hcl CHANGE UM: QUANTITY 1 / Day 3 / Day
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 103 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 pramipexole dihydrochloride,m irapex
pramipexole di-hcl CHANGE UM: QUANTITY 1 / Day 3 / Day
06/01/2016 mirapex,pramipe xole dihydrochloride
pramipexole di-hcl CHANGE UM: QUANTITY 1 / Day 3 / Day
06/01/2016 pramipexole dihydrochloride,m irapex
pramipexole di-hcl CHANGE UM: QUANTITY 1 / Day 3 / Day
06/01/2016 pantoprazole sodium
pantoprazole sodium ADD UM: QUANTITY 2 / Day
06/01/2016 pantoprazole sodium,protonix
pantoprazole sodium CHANGE UM: QUANTITY 1 / Day 2 / Day
06/01/2016 nystatin nystatin ADD UM: QUANTITY 40 / 1 days
06/01/2016 mycophenolate mofetil,cellcept
mycophenolate mofetil ADD UM: QUANTITY 1 / Day
06/01/2016 tamsulosin hcl,flomax
tamsulosin hcl CHANGE UM: QUANTITY 1 / Day 2 / Day
06/01/2016 nitrofurantoin mono- macro,macrobid
nitrofurantoin monohydrate/macrocrystals
CHANGE UM: QUANTITY 1 / Day 2 / Day
06/01/2016 gavilyte-n,peg 3350- electrolyte,peg- 3350 with flavor packs,trilyte with flavor packets,nulytely with flavor packs,nulytely
sodium chloride/sodium bicarbonate/potassium chloride/peg
ADD UM: QUANTITY 134 / 1 days
06/01/2016 acyclovir,zovirax acyclovir CHANGE UM: QUANTITY 2 / Day 5 / Day 06/01/2016 acyclovir,zovirax acyclovir CHANGE UM: QUANTITY 2 / Day 5 / Day
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 104 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 acyclovir,zovirax acyclovir CHANGE UM: QUANTITY 1 / Day 5 / Day 06/01/2016 vitamin b-
6,pyridoxine hcl pyridoxine hcl (vitamin b6),pyridoxine hcl
ADD UM: QUANTITY 4 / Day
06/01/2016 diltiazem hcl diltiazem hcl ADD UM: QUANTITY 3 / 1 days
06/01/2016 CARDIZEM diltiazem hcl ADD UM: QUANTITY 1 / Day
06/01/2016 diltiazem hcl diltiazem hcl ADD UM: QUANTITY 3 / 1 days
06/01/2016 CARDIZEM diltiazem hcl ADD UM: QUANTITY 1 / Day
06/01/2016 diltiazem hcl diltiazem hcl ADD UM: QUANTITY 3 / 1 days
06/01/2016 CARDIZEM diltiazem hcl ADD UM: QUANTITY 1 / Day
06/01/2016 diltiazem hcl diltiazem hcl ADD UM: QUANTITY 3 / 1 days
06/01/2016 CARDIZEM diltiazem hcl ADD UM: QUANTITY 4 / Day
06/01/2016 hydralazine hcl hydralazine hcl ADD UM: QUANTITY 4 / Day 06/01/2016 hydralazine hcl hydralazine hcl CHANGE UM: QUANTITY 3 / days 4 / Day 06/01/2016 hydralazine hcl hydralazine hcl ADD UM: QUANTITY 4 / Day 06/01/2016 vitamin b-6 pyridoxine hcl (vitamin b6) ADD UM: QUANTITY
06/01/2016 vitamin b- 6,pyridoxine hcl
pyridoxine hcl (vitamin b6),pyridoxine hcl
ADD UM: QUANTITY 4 / Day
06/01/2016 pulmicort,budeso nide
budesonide ADD UM: QUANTITY 4 / Day
06/01/2016 budesonide budesonide CHANGE UM: QUANTITY 2 / Day 4 / Day 06/01/2016 penlac,ciclodan,ci
clopirox ciclopirox ADD UM: QUANTITY 6.6 / 28 days
06/01/2016 colchicine,colcrys colchicine CHANGE UM: QUANTITY 4 / Day 2 / Day 06/01/2016 CREON lipase/protease/amylase ADD UM: QUANTITY 90 / days
06/01/2016 CREON lipase/protease/amylase ADD UM: QUANTITY 42 / days
06/01/2016 CREON lipase/protease/amylase ADD UM: QUANTITY 336 / days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 105 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 CREON lipase/protease/amylase ADD UM: QUANTITY 28 / days
06/01/2016 CREON lipase/protease/amylase ADD UM: QUANTITY 168 / days
06/01/2016 isosorbide mononitrate er,imdur
isosorbide mononitrate CHANGE UM: QUANTITY 1 / Day 2 / Day
06/01/2016 nimodipine nimodipine ADD UM: QUANTITY 1 / Day
06/01/2016 oxycodone hcl oxycodone hcl ADD UM: QUANTITY 20 / DAY 06/01/2016 VICTOZA 3-
PAK,VICTOZA 2- PAK
liraglutide CHANGE UM: QUANTITY 0.134 / Day 9 / 30 DAYS
06/01/2016 THERMAZENE silver sulfadiazine ADD TO FORMULARY Non-Formulary Covered 06/01/2016 lovenox,enoxapar
in sodium enoxaparin sodium REMOVE UM:
AUTHORIZATION
06/01/2016 elimite permethrin REMOVE UM: QUANTITY
06/01/2016 OVIDE malathion REMOVE UM: QUANTITY 1.97 / day
06/01/2016 ZEMPLAR paricalcitol REMOVE FROM FORMULARY
Covered Non-Formulary
06/01/2016 HECTOROL doxercalciferol REMOVE FROM FORMULARY
Covered Non-Formulary
06/01/2016 pain reliever acetaminophen CHANGE TIER Covered 06/01/2016 pain reliever acetaminophen CHANGE UM: QUANTITY 4 / days 06/01/2016 infants'
acetaminophen acetaminophen ADD TO FORMULARY Covered
06/01/2016 infants' acetaminophen
acetaminophen ADD UM: QUANTITY 125 / days
06/01/2016 infants' acetaminophen
acetaminophen ADD UM: CUSTOM Cumulative APAP 4gm/day
Edit 06/01/2016 ibuprofen,ibu ibuprofen CHANGE TIER Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 106 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 children's ibuprofen
ibuprofen CHANGE TIER Covered
06/01/2016 naproxen naproxen CHANGE TIER Covered 06/01/2016 naproxen naproxen CHANGE TIER Covered 06/01/2016 naproxen naproxen CHANGE TIER Covered 06/01/2016 naproxen sodium naproxen sodium CHANGE TIER Covered 06/01/2016 naproxen sodium naproxen sodium CHANGE TIER Covered 06/01/2016 LANTUS
SOLOSTAR insulin glargine,human recombinant analog,insulin glargine, human recombinant analog
REMOVE UM: QUANTITY 0.667 / day
06/01/2016 FIORINAL WITH CODEINE #3
codeine phosphate/butalbital/aspirin/ caffeine
REMOVE FROM FORMULARY
Covered Non-Formulary
06/01/2016 FIORINAL WITH CODEINE #3
codeine phosphate/butalbital/aspirin/ caffeine
REMOVE UM: QUANTITY 8 / Day
06/01/2016 RENVELA sevelamer carbonate REMOVE FROM FORMULARY
Covered Non-Formulary
06/01/2016 RENVELA sevelamer carbonate REMOVE UM: AUTHORIZATION
PA applies
06/01/2016 sevelamer carbonate
sevelamer carbonate REMOVE UM: AUTHORIZATION
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 107 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 modicon,ortho- novum,ovcon- 35,ovcon- 50,nortrel,balziva, aranelle,gildagia, cyclafem,dasetta, philith,wera,neco n,zenchent,leena, brevicon,norinyl 1-35,tri- norinyl,norinyl 1+35,briellyn,alya cen,pirmella,vyfe mla
norethindrone-ethinyl estradiol
ADD UM: QUANTITY 84 / 84 days
06/01/2016 ortho tri-cyclen lo,ortho- cyclen,ortho tri- cyclen,sprintec,tri - sprintec,previfem, tri- previfem,estarylla ,tri- estarylla,mono- linyah,tri- linyah,trinessa,m ononessa,norges timate-ethinyl estradiol,tri-lo- sprintec,tri-lo- estarylla,trinessa lo,tri-lo- marzia,femynor,tr i femynor
norgestimate-ethinyl estradiol
ADD UM: QUANTITY 84 / 84 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 108 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 micronor,errin,ca mila,ortho micronor,norethin drone,nor-q- d,nora- be,jolivette,heath er,jencycla,lyza,n orlyroc,sharobel, deblitane,norlyda
norethindrone ADD UM: QUANTITY 84 / 84 days
06/01/2016 kariva,mircette,az urette,viorele,pim trea,desogestr- eth estrad eth estra,kimidess,be kyree
desogestrel-ethinyl estradiol/ethinyl estradiol
ADD UM: QUANTITY 84 / 84 days
06/01/2016 desogen,cycless a,ortho- cept,apri,velivet,e moquette,reclipse n,caziant,solia,ce sia,enskyce,deso gestrel-ethinyl estradiol,cyred,jul eber,isibloom
desogestrel-ethinyl estradiol ADD UM: QUANTITY 84 / 84 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 109 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 lo loestrin fe,loestrin 24 fe,estrostep fe,junel fe,tri- legest fe,gildess fe,tilia fe,microgestin fe,loestrin fe,minastrin 24 fe,lo minastrin fe,larin fe,lomedia 24 fe,norethin-eth estra-ferrous fum,tarina fe,gildess 24 fe,larin 24 fe,junel fe 24,blisovi fe,blisovi 24 fe,microgestin 24 fe,taytulla,mibela s 24 fe,melodetta 24 fe
norethindrone acetate- ethinyl estradiol/ferrous fumarate
ADD UM: QUANTITY 84 / 84 days
06/01/2016 gianvi,ocella,lory na,syeda,yaz,yas min 28,zarah,vestura, drospirenone- ethinyl estradiol,nikki
ethinyl estradiol/drospirenone
ADD UM: QUANTITY 84 / 84 days
06/01/2016 lessina,aviane,or sythia,falmina,lut era,sronyx,levono rgestrel-eth estradiol,aubra,d elyla,vienva,lariss ia
levonorgestrel-ethinyl estradiol
ADD UM: QUANTITY 84 / 84 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 110 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 necon,norinyl 1+50,ortho- novum
norethindrone-mestranol ADD UM: QUANTITY 84 / 84 days
06/01/2016 kelnor 1-35,zovia 1-35e,ethynodiol- ethinyl estradiol
ethynodiol diacetate-ethinyl estradiol
ADD UM: QUANTITY 84 / 84 days
06/01/2016 zovia 1- 50e,demulen 1- 50-28,ethynodiol- ethinyl estradiol
ethynodiol diacetate-ethinyl estradiol
ADD UM: QUANTITY 84 / 84 days
06/01/2016 kelnor 1-35,zovia 1-35e,zovia 1- 50e,demulen 1- 50-28,ethynodiol- ethinyl estradiol
ethynodiol diacetate-ethinyl estradiol
ADD UM: QUANTITY 84 / 84 days
06/01/2016 lybrel,levonorgest rel-eth estradiol,lessina, portia,aviane,enp resse,jolessa,my zilra,orsythia,alta vera,introvale,lev onest,falmina,lute ra,trivora- 28,levora- 28,chateal,levlen 28,seasonale,nor dette- 28,amethyst,quas ense,sronyx,nord ette- 8,kurvelo,marliss a,aubra,delyla,set lakin,vienva,lariss ia,lillow
levonorgestrel-ethinyl estradiol
ADD UM: QUANTITY 84 / 84 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 111 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 junel,gildess,loest rin,microgestin,lar in,norethindron- ethinyl estradiol
norethindrone acetate- ethinyl estradiol
ADD UM: QUANTITY 84 / 84 days
06/01/2016 lo-ovral- 28,cryselle,elines t,norgestrel- ethiny estra,low- ogestrel,ogestrel,l o-ovral-8,lo-ovral- 21,ovral-21,ovral- 28
norgestrel-ethinyl estradiol ADD UM: QUANTITY 84 / 84 days
06/01/2016 baclofen baclofen REMOVE UM: AGE 0 to 64 yrs old
06/01/2016 baclofen baclofen REMOVE UM: AGE 0 to 64 yrs old
06/01/2016 glucotrol,glipizide glipizide REMOVE UM: QUANTITY
06/01/2016 folic acid folic acid REMOVE UM: QUANTITY
06/01/2016 peg-3350 and electrolytes,gavily te-g,golytely
peg 3350/sod sulf/sod bicarb/sod chloride/potassium chloride
REMOVE UM: QUANTITY 134 / 1 days
06/01/2016 colyte with flavor packets,gavilyte- c,peg 3350- electrolyte
peg 3350/sod sulf/sod bicarb/sod chloride/potassium chloride,peg 3350/sod sulf/sod bicarbonate/sod chloride/potassium chl
REMOVE UM: QUANTITY 134 / 1 days
06/01/2016 sandimmune,cycl osporine
cyclosporine REMOVE UM: QUANTITY 5 / Day
06/01/2016 sandimmune,cycl osporine
cyclosporine REMOVE UM: QUANTITY 16 / Day
06/01/2016 gengraf,neoral,cy closporine modified,cyclosp orine
cyclosporine, modified REMOVE UM: QUANTITY
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 112 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/01/2016 magic bullet bisacodyl REMOVE FROM FORMULARY
Covered Non-Formulary
06/01/2016 magic bullet bisacodyl REMOVE UM: QUANTITY 1 / Day
06/01/2016 DULCOLAX bisacodyl REMOVE UM: QUANTITY 1 / Day
06/01/2016 bisacodyl bisacodyl ADD TO FORMULARY Non-Formulary Covered 06/02/2016 tramadol hcl tramadol hcl CHANGE TIER Covered 06/02/2016 thera-d cholecalciferol (vitamin d3) REMOVE FROM
FORMULARY Covered Non-Formulary
06/02/2016 d3 dots cholecalciferol (vitamin d3) REMOVE FROM FORMULARY
Covered Non-Formulary
06/02/2016 calcitrate calcium citrate REMOVE FROM FORMULARY
Covered Non-Formulary
06/03/2016 methadone hcl methadone hcl CHANGE UM: QUANTITY 8 / Day 4 / days 06/03/2016 methadone hcl methadone hcl CHANGE UM: QUANTITY 8 / Day 4 / days 06/06/2016 carisoprodol carisoprodol CHANGE TIER Covered Not Covered 06/06/2016 ortho tri-cyclen
lo,tri-lo- sprintec,norgesti mate-ethinyl estradiol,tri-lo- estarylla,trinessa lo,tri-lo-marzia
norgestimate-ethinyl estradiol
ADD UM: QUANTITY 28 / 28 days
06/06/2016 NUVARING etonogestrel/ethinyl estradiol CHANGE UM: QUANTITY 0.034 / Day 1 / 28 days 06/06/2016 hydralazine hcl hydralazine hcl ADD UM: QUANTITY 4 / 1 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 113 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/06/2016 ortho tri- cyclen,tri- sprintec,tri- previfem,tri- estarylla,tri- linyah,trinessa,no rgestimate-ethinyl estradiol
norgestimate-ethinyl estradiol
ADD UM: QUANTITY 84 / 84 days
06/06/2016 levonorgestrel- eth estradiol,portia,alt avera,levora- 28,chateal,levlen 28,nordette- 28,nordette- 8,kurvelo,marliss a
levonorgestrel-ethinyl estradiol
ADD UM: QUANTITY 84 / 84 days
06/06/2016 nasacort,children' s nasacort,nasal allergy
triamcinolone acetonide CHANGE UM: QUANTITY 0.563 / days
06/06/2016 pulmicort,budeso nide
budesonide CHANGE UM: QUANTITY 2 / days
06/06/2016 ipratropium- albuterol
ipratropium bromide/albuterol sulfate
CHANGE UM: QUANTITY 3 / days
06/06/2016 furosemide furosemide CHANGE TIER Covered 06/06/2016 furosemide furosemide CHANGE TIER Covered 06/07/2016 tramadol hcl tramadol hcl CHANGE UM: QUANTITY 8 / 1 days 06/07/2016 NICOTROL nicotine CHANGE UM: QUANTITY 0.034 / Day 168 / 30 days 06/07/2016 albuterol
sulfate,accuneb albuterol sulfate CHANGE UM: QUANTITY 7.5 / day 22.5 / 1 days
06/07/2016 albuterol sulfate,accuneb
albuterol sulfate CHANGE UM: QUANTITY 7.5 / day 22.5 / 1 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 114 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/07/2016 ipratropium- albuterol,duoneb
ipratropium bromide/albuterol sulfate
CHANGE UM: QUANTITY 18 / 1 days
06/07/2016 fentanyl,duragesi c
fentanyl CHANGE UM: QUANTITY 0.34 / 1 days
06/07/2016 fentanyl,duragesi c
fentanyl CHANGE UM: QUANTITY 0.34 / 1 days
06/07/2016 fentanyl,duragesi c
fentanyl CHANGE UM: QUANTITY 0.34 / 1 days
06/07/2016 fentanyl,duragesi c
fentanyl CHANGE UM: QUANTITY 0.34 / 1 days
06/07/2016 fentanyl,duragesi c
fentanyl CHANGE UM: QUANTITY 0.34 / 1 days
06/07/2016 lisinopril lisinopril CHANGE TIER Covered 06/07/2016 lisinopril lisinopril CHANGE UM: QUANTITY 1.5 / days 06/07/2016 nasacort,children'
s nasacort,nasal allergy
triamcinolone acetonide CHANGE UM: QUANTITY 0.563 / days 0.564 / 1 days
06/08/2016 auvi- q,adrenaclick,epi nephrine
epinephrine CHANGE UM: QUANTITY .0667 / days
06/08/2016 EPIPEN JR,EPIPEN JR 2- PAK
epinephrine CHANGE UM: QUANTITY .667 / 1 days .0667 / 1 days
06/08/2016 auvi- q,epinephrine,epi pen,epipen 2- pak,adrenaclick
epinephrine CHANGE UM: QUANTITY .0667 / 1 days
06/09/2016 aldactone,spirono lactone
spironolactone CHANGE UM: QUANTITY 2 / 1 days
06/09/2016 aldactone,spirono lactone
spironolactone CHANGE UM: QUANTITY 2 / 1 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 115 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/09/2016 aldactone,spirono lactone
spironolactone CHANGE UM: QUANTITY 2 / 1 days
06/09/2016 requip,ropinirole hcl
ropinirole hcl CHANGE UM: QUANTITY 3 / days
06/09/2016 requip,ropinirole hcl
ropinirole hcl CHANGE UM: QUANTITY 3 / days
06/09/2016 requip,ropinirole hcl
ropinirole hcl CHANGE UM: QUANTITY 3 / days
06/09/2016 requip,ropinirole hcl
ropinirole hcl CHANGE UM: QUANTITY 3 / days
06/09/2016 requip,ropinirole hcl
ropinirole hcl CHANGE UM: QUANTITY 3 / days
06/09/2016 requip,ropinirole hcl
ropinirole hcl CHANGE UM: QUANTITY 3 / days
06/09/2016 requip,ropinirole hcl
ropinirole hcl CHANGE UM: QUANTITY 3 / days
06/09/2016 minipress,prazosi n hcl
prazosin hcl REMOVE UM: QUANTITY
06/09/2016 minipress,prazosi n hcl
prazosin hcl REMOVE UM: QUANTITY
06/09/2016 minipress,prazosi n hcl
prazosin hcl REMOVE UM: QUANTITY
06/09/2016 lasix,furosemide furosemide CHANGE UM: QUANTITY 8 / days 06/09/2016 lasix,furosemide furosemide CHANGE UM: QUANTITY 4 / days 06/09/2016 furosemide furosemide CHANGE TIER Covered 06/09/2016 lasix,furosemide furosemide CHANGE UM: QUANTITY 16 / days 06/10/2016 benzamycin,eryth
romycin-benzoyl peroxide
erythromycin base/benzoyl peroxide
CHANGE UM: QUANTITY 1.553 / day 1.554 / days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 116 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/13/2016 metformin hcl metformin hcl CHANGE TIER Covered 06/13/2016 metformin hcl metformin hcl CHANGE UM: QUANTITY 4 / 1 days 4 / days 06/14/2016 SPIRIVA
RESPIMAT tiotropium bromide CHANGE UM: QUANTITY 0.133 / day 0.134 / days
06/27/2016 clarithromycin clarithromycin REMOVE UM: AGE Up to 12 yrs old
06/27/2016 biaxin,clarithromy cin
clarithromycin REMOVE UM: AGE
06/27/2016 omnicef,cefdinir cefdinir REMOVE UM: AGE Up to 12 yrs old
06/27/2016 omnicef,cefdinir cefdinir REMOVE UM: AGE Up to 12 yrs old
06/27/2016 augmentin es- 600,amoxicillin- clavulanate potass,amox tr- potassium clavulanate
amoxicillin/potassium clavulanate
REMOVE UM: AGE Up to 12 yrs old
06/27/2016 augmentin,amoxi cillin-clavulanate potass
amoxicillin/potassium clavulanate
REMOVE UM: AGE
06/27/2016 amoxicillin- clavulanate potass,amox tr- potassium clavulanate
amoxicillin/potassium clavulanate
REMOVE UM: AGE Up to 12 yrs old
06/27/2016 amoxicillin- clavulanate potass,amox tr- potassium clavulanate,augm entin
amoxicillin/potassium clavulanate
REMOVE UM: AGE Up to 12 yrs old
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 117 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/27/2016 augmentin,amoxi cillin-clavulanate potass,amox tr- potassium clavulanate
amoxicillin/potassium clavulanate
REMOVE UM: AGE Up to 12 yrs old
06/27/2016 amoxicillin- clavulanate potass,amox tr- potassium clavulanate
amoxicillin/potassium clavulanate
REMOVE UM: AGE Up to 12 yrs old
06/27/2016 cefprozil,cefzil cefprozil REMOVE UM: AGE Up to 12 yrs old
06/27/2016 cefprozil,cefzil cefprozil REMOVE UM: AGE Up to 12 yrs old
06/27/2016 penicillin v potassium
penicillin v potassium REMOVE UM: AGE Up to 12 yrs old
06/27/2016 penicillin v potassium
penicillin v potassium REMOVE UM: AGE Up to 12 yrs old
06/27/2016 ampicillin trihydrate
ampicillin trihydrate REMOVE UM: AGE Up to 12 yrs old
06/27/2016 ampicillin trihydrate
ampicillin trihydrate REMOVE UM: AGE Up to 12 yrs old
06/27/2016 amoxicillin amoxicillin REMOVE UM: AGE Up to 12 yrs old
06/27/2016 amoxicillin,amoxil amoxicillin REMOVE UM: AGE
06/27/2016 amoxicillin,amoxil amoxicillin REMOVE UM: AGE Up to 12 yrs old
06/27/2016 amoxicillin,amoxil amoxicillin REMOVE UM: AGE Up to 12 yrs old
06/27/2016 cephalexin cephalexin REMOVE UM: AGE Up to 12 yrs old
06/27/2016 cephalexin cephalexin REMOVE UM: AGE Up to 12 yrs old
06/27/2016 cefaclor,ceclor cefaclor REMOVE UM: AGE Up to 12 yrs old
06/27/2016 cefaclor,ceclor cefaclor REMOVE UM: AGE Up to 12 yrs old
06/27/2016 cefaclor cefaclor REMOVE UM: AGE Up to 12 yrs old
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 118 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
06/27/2016 cefadroxil cefadroxil,cefadroxil hydrate REMOVE UM: AGE Up to 12 yrs old
06/27/2016 cefadroxil cefadroxil,cefadroxil hydrate REMOVE UM: AGE Up to 12 yrs old
06/27/2016 zithromax,azithro mycin
azithromycin REMOVE UM: AGE Up to 12 yrs old
06/27/2016 zithromax,azithro mycin
azithromycin REMOVE UM: AGE Up to 12 yrs old
06/27/2016 cefpodoxime proxetil
cefpodoxime proxetil REMOVE UM: AGE Up to 12 yrs old
06/27/2016 cefpodoxime proxetil
cefpodoxime proxetil REMOVE UM: AGE Up to 12 yrs old
06/29/2016 stool softener,sof- lax,docusate sodium,dulcolax stool softener,doc-q- lace,docusoft s,dok,docu soft,col- rite,phillips' laxative,womens stool softener,colace,d ss,docusil,dulcoe ase,correctol extra gentle,genasoft,u ni-ease,woman's laxative-docusate sod
docusate sodium REMOVE UM: QUANTITY 1 / days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 119 UPDATED 10/2018
July, 2016
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2016 RENVELA sevelamer carbonate REMOVE FROM
FORMULARY Covered Non-Formulary
07/01/2016 RENVELA sevelamer carbonate REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 120 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
07/01/2016 child triaminic fever reducer,children's tylenol,tylenol extra strength,children' s tylenol meltaways,tylenol arthritis,infant triaminic fever reducer,triaminic fever reducer,infant's pain relief,pain relief extra strength,children' s pain relief,pain relief,arthritis pain,acetaminoph en,genebs,infants ' pain reliever,pain reliever,children's non- aspirin,infants' pain-fever,non- aspirin,arthritis pain relief,arthritis pain reliever,junior pain reliever,jr pain & fever,child pain rel-fever reducer,children's fever reducer,infants tylenol,infants' tylenol,tylenol 8 hour,tylenol,jr.
acetaminophen REMOVE UM: QUANTITY
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 121 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
tylenol meltaways,tylenol sore throat,feverall,ed- apap,children's pain and fever,pain & fever,children's pain & fever,children's pain-fever,q- pap,q-pap extra strength,children' s q- pap,acephen,ma pap,mapap infant,children's mapap,junior mapap,mapap arthritis pain,infants' mapap,non- aspirin extra strength,children' s pain reliever,pain reliever junior strength,8 hour pain relief,non- aspirin jr strength,infant's non- aspirin,infant's pain reliever,acetamin ophen extra strength,jr acetaminophen,f ever reducer-pain
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 122 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
reliever,acetamin ophen er,athenol,infant fever-pain reliever,child pain relief,masophen,t ylophen,pediacar e fever reducer,extra strength non- aspirin,pharbetol, acetaminophen pain relief,fever reducer,infant's acetaminophen,a cetadrink,genapa p,silapap,extende d pain relief,infants pain reliever,non- aspirin pain relief,acetaminop hen 8 hour,infants' non- aspirin,jr. str non- aspirin pain,8 hour pain reliever,jr. strength pain reliever,child non- aspirin,jr. str non- aspirin,non- aspirin 8 hour,infant pain- fever,children's acetaminophen,a spirin free,ofirmev,child' s accudial
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 123 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
acetaminophen,in fant pain relief,8 hour,children's easy-melts,medi- tabs,medi-tabs extra strength,children' s medi- tabs,medi-tabs pain reliever,pain relief cool ice,infants' pain relief,children's fever reducing,pain relief adult,tylenol extra strength arthrit,betatemp,c hildren's silapap,little fevers,little remedies fever- pain,infantaire,tac tinal,children's tactinal,nortemp, aphen,acetamino phen es,infants concentrated,chil drens acetaminophen,a pra,maxapap,ace taminophen junior strength,acetami nophen pain reliever,childrens suspension,infant acetaminophen,p ain reliever w-o
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 124 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
aspirin,pain relief junior strength,st. joseph asa-free children's,st. joseph,st. joseph fever reducer,infants aspirin free,jr. acetaminophen,p ain reliever-fever reducer,shake that ache,juniors' acetaminophen,in fants' acetaminophen
07/01/2016 tizanidine hcl,zanaflex
tizanidine hcl REMOVE FROM FORMULARY
Non-Formulary
07/01/2016 HUMIRA,HUMIR A PEN,HUMIRA PEN CROHN- UC-HS STARTER,HUMI RA PEN PSORIASIS- UVEITIS,HUMIR A PEDIATRIC CROHN'S
adalimumab REMOVE UM: AUTHORIZATION
07/01/2016 ZENPEP lipase/protease/amylase ADD TO FORMULARY Non-Formulary Covered 07/01/2016 pancrelipase
5,000,zenpep lipase/protease/amylase ADD UM: QUANTITY 720 / 30 days
07/01/2016 ZENPEP lipase/protease/amylase ADD UM: QUANTITY 720 / 30 days 07/01/2016 ZENPEP lipase/protease/amylase ADD UM: QUANTITY 480 / 30 days 07/01/2016 ZENPEP lipase/protease/amylase ADD UM: QUANTITY 480 / 30 days 07/01/2016 CREON lipase/protease/amylase ADD UM: QUANTITY 480 / 30 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 125 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
07/01/2016 PANCREAZE lipase/protease/amylase ADD UM: QUANTITY 480 / 30 days 07/01/2016 PANCREAZE lipase/protease/amylase ADD UM: QUANTITY 480 / 30 days 07/01/2016 PANCREAZE lipase/protease/amylase ADD UM: QUANTITY 480 / 30 days 07/01/2016 ZENPEP lipase/protease/amylase ADD UM: QUANTITY 480 / 30 days 07/01/2016 ZENPEP lipase/protease/amylase ADD TO FORMULARY Covered 07/01/2016 ZENPEP lipase/protease/amylase ADD UM: QUANTITY 480 / 30 days 07/01/2016 ZENPEP lipase/protease/amylase ADD TO FORMULARY Covered 07/07/2016 proventil
hfa,ventolin hfa,proair hfa,albuterol sulfate hfa
albuterol sulfate CHANGE UM: QUANTITY 0.6 / day 18 / 30 days
07/11/2016 FLUCELVAX QUAD 2016- 2017
flu vaccine qs 2016-2017(4 years and older)cell derived/pf
ADD TO FORMULARY Covered
07/11/2016 FLUCELVAX QUAD 2016- 2017
flu vaccine qs 2016-2017(4 years and older)cell derived/pf
ADD UM: QUANTITY 1 / 270 days
07/11/2016 FLUMIST QUAD 2016-2017
influenza vaccine quadrivalent live 2016-2017 (2 yrs-49 yrs)
ADD TO FORMULARY Covered
07/11/2016 FLUMIST QUAD 2016-2017
influenza vaccine quadrivalent live 2016-2017 (2 yrs-49 yrs)
ADD UM: QUANTITY 1 / 270 days
07/11/2016 FLULAVAL QUAD 2016- 2017
influenza virus vaccine qvalsplit 2016-2017(6 mos and older)
ADD TO FORMULARY Covered
07/11/2016 FLULAVAL QUAD 2016- 2017
influenza virus vaccine qvalsplit 2016-2017(6 mos and older)
ADD UM: QUANTITY 1 / 270 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 126 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
07/11/2016 FLUZONE QUAD PEDI 2016-2017
influenza virus vaccine quadrival 2016-17 (6 mos- 35 mos)/pf
ADD TO FORMULARY Covered
07/11/2016 FLUZONE QUAD PEDI 2016-2017
influenza virus vaccine quadrival 2016-17 (6 mos- 35 mos)/pf
ADD UM: QUANTITY 1 / 270 days
07/11/2016 FLUZONE INTRADERM QUAD 2016-17
influenza virus vaccine quadrivalent 2016-17(18yrs- 64yrs)/pf
ADD TO FORMULARY Covered
07/11/2016 FLUZONE INTRADERM QUAD 2016-17
influenza virus vaccine quadrivalent 2016-17(18yrs- 64yrs)/pf
ADD UM: QUANTITY 1 / 270 days
07/11/2016 FLUZONE QUAD 2016-2017
influenza virus vaccine quadval split 2016-17(36 mos up)/pf
ADD TO FORMULARY Covered
07/11/2016 FLUZONE QUAD 2016-2017
influenza virus vaccine quadval split 2016-17(36 mos up)/pf
ADD UM: QUANTITY 1 / 270 days
07/11/2016 FLUZONE QUAD 2016-2017
influenza virus vaccine quadval split 2016-17(36 mos up)/pf
ADD TO FORMULARY Covered
07/11/2016 FLUZONE QUAD 2016-2017
influenza virus vaccine quadval split 2016-17(36 mos up)/pf
ADD UM: QUANTITY 1 / 270 days
07/11/2016 FLULAVAL QUAD 2016- 2017
influenza virus vaccine qvalsplit 2016-2017(6 mos and up)/pf
ADD TO FORMULARY Covered
07/11/2016 FLULAVAL QUAD 2016- 2017
influenza virus vaccine qvalsplit 2016-2017(6 mos and up)/pf
ADD UM: QUANTITY 1 / 270 days
07/11/2016 FLUZONE QUAD 2016-2017
influenza virus vaccine qvalsplit 2016-2017(6 mos and older)
ADD TO FORMULARY Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 127 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
07/11/2016 FLUZONE QUAD 2016-2017
influenza virus vaccine qvalsplit 2016-2017(6 mos and older)
ADD UM: QUANTITY 1 / 270 days
07/11/2016 FLUVIRIN 2016- 2017
influenza virus vaccine trival 2016-2017 (4yr and older)/pf
ADD TO FORMULARY Covered
07/11/2016 FLUVIRIN 2016- 2017
influenza virus vaccine trival 2016-2017 (4yr and older)/pf
ADD UM: QUANTITY 1 / 270 days
07/11/2016 FLUZONE HIGH- DOSE 2016-2017
influenza virus vaccine trival split 2016-2017(65 yr up)/pf
ADD TO FORMULARY Covered
07/11/2016 FLUZONE HIGH- DOSE 2016-2017
influenza virus vaccine trival split 2016-2017(65 yr up)/pf
ADD UM: QUANTITY 1 / 270 days
07/11/2016 FLUVIRIN 2016- 2017
influenza virus vaccine trivalent 2016-2017 (4 yr and older)
ADD TO FORMULARY Covered
07/11/2016 FLUVIRIN 2016- 2017
influenza virus vaccine trivalent 2016-2017 (4 yr and older)
ADD UM: QUANTITY 1 / 270 days
07/11/2016 AFLURIA 2016- 2017
influenza virus vaccine trivalent 2016-2017 (5 years up)/pf
ADD TO FORMULARY Covered
07/11/2016 AFLURIA 2016- 2017
influenza virus vaccine trivalent 2016-2017 (5 years up)/pf
ADD UM: QUANTITY 1 / 270 days
07/11/2016 AFLURIA 2016- 2017
influenza virus vaccine trivalent 2016-2017 (5 yr and older)
ADD TO FORMULARY Covered
07/11/2016 AFLURIA 2016- 2017
influenza virus vaccine trivalent 2016-2017 (5 yr and older)
ADD UM: QUANTITY 1 / 270 days
07/11/2016 FLUBLOK 2016- 2017
influenza virus vaccine tv 2016-17(18 yrs and older)rcmb/pf
ADD TO FORMULARY Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 128 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
07/11/2016 FLUBLOK 2016- 2017
influenza virus vaccine tv 2016-17(18 yrs and older)rcmb/pf
ADD UM: QUANTITY 1 / 270 days
07/11/2016 FLUARIX QUAD 2016-2017
influenza virus vaccine quadval split 2016-17(36 mos up)/pf
ADD TO FORMULARY Covered
07/11/2016 FLUARIX QUAD 2016-2017
influenza virus vaccine quadval split 2016-17(36 mos up)/pf
ADD UM: QUANTITY 1 / 270 days
07/13/2016 constulose lactulose REMOVE FROM FORMULARY
Covered Non-Formulary
07/13/2016 lactulose lactulose REMOVE UM: CUSTOM Carveout Drug - Bill MDCH FFS
07/13/2016 lactulose lactulose ADD UM: CUSTOM Bill MDCH FFS 07/14/2016 CABOMETYX cabozantinib s-malate ADD UM: CUSTOM Bill MDCH FFS 07/14/2016 lithostat,enulose,
sodium phenylbutyrate,la ctulose,carbaglu, generlac,buphen yl,ammonul,ravict i,sodium phenylacet-sod benzoate
acetohydroxamic acid,lactulose,sodium phenylbutyrate,carglumic acid,sodium benzoate/sodium phenylacetate,glycerol phenylbutyrate
CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
07/27/2016 gengraf,neoral,cy closporine modified,cyclosp orine
cyclosporine, modified CHANGE UM: AGE 0 to 12 yrs old
07/27/2016 gengraf,neoral,cy closporine modified,cyclosp orine
cyclosporine, modified REMOVE UM: QUANTITY
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 129 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
07/31/2016 INJECTAFER ferric carboxymaltose REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 130 UPDATED 10/2018
August, 2016
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/01/2016 FLUMIST QUAD
2015-2016 influenza vaccine quadrivalent live 2015-2016 (2 yrs-49 yrs)
REMOVE FROM FORMULARY
Covered Non-Formulary
08/01/2016 FLUMIST QUAD 2016-2017
influenza vaccine quadrivalent live 2016-2017 (2 yrs-49 yrs)
REMOVE FROM FORMULARY
Covered Non-Formulary
08/01/2016 DELZICOL mesalamine ADD TO FORMULARY Covered 08/01/2016 calcipotriene,sori
l ux,dovonex,calcit
l i t i l
calcipotriene REMOVE UM: AUTHORIZATION
08/15/2016 prenatal vitamin plus low iron
prenatal vits with calcium no.72/ferrous fumarate/folic acid
CHANGE TIER Covered
08/15/2016 preplus prenatal vits with calcium no.72/ferrous fumarate/folic acid
REMOVE FROM FORMULARY
Covered Non-Formulary
08/15/2016 METANX levomefolate calc/pyridoxal phos/mecobalamin/schiz.alg al oil
REMOVE FROM FORMULARY
Covered Non-Formulary
08/15/2016 CEREFOLIN NAC
levomefolate cal/acetylcysteine/mecobala min/schiz.algal oil
REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 131 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
08/15/2016 sprycel,bosulif,inl yta,sutent,xalkori, gleevec,tasigna,t ykerb,votrient,ires sa,vandetanib,ca prelsa,cometriq,t arceva,zelboraf,st ivarga,nexavar,ve lcade,kyprolis,iclu sig,tafinlar,gilotrif, imbruvica,zykadi a,zydelig,lynparz a,ibrance,lenvima ,tagrisso,ninlaro,a lecensa,imatinib mesylate,cabome tyx
dasatinib,bosutinib,axitinib,s unitinib malate,crizotinib,imatinib mesylate,nilotinib hcl,lapatinib ditosylate,pazopanib hcl,gefitinib,vandetanib,cabo zantinib s-malate,erlotinib hcl,vemurafenib,regorafenib, sorafenib tosylate,bortezomib,carfilzo mib,ponatinib hcl,dabrafenib mesylate,afatinib dimaleate,ibrutinib,ceritinib,i delalisib,olaparib,palbociclib, lenvatinib mesylate,osimertinib mesylate,ixazomib citrate,alectinib hcl
CHANGE UM: CUSTOM BILL MDCH FFS
08/15/2016 SYNTHROID levothyroxine sodium ADD UM: CUSTOM Must be billed with a DAW Code
of 0 08/15/2016 SYNTHROID levothyroxine sodium ADD UM: CUSTOM Must be billed
with a DAW Code of 0
08/15/2016 SYNTHROID levothyroxine sodium ADD UM: CUSTOM Must be billed with a DAW Code
of 0 08/15/2016 SYNTHROID levothyroxine sodium ADD UM: CUSTOM Must be billed
with a DAW Code of 0
08/15/2016 SYNTHROID levothyroxine sodium ADD UM: CUSTOM Must be billed with a DAW Code
of 0
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 132 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
08/15/2016 SYNTHROID levothyroxine sodium ADD UM: CUSTOM Must be billed with a DAW Code
of 0 08/15/2016 SYNTHROID levothyroxine sodium ADD UM: CUSTOM Must be billed
with a DAW Code of 0
08/15/2016 SYNTHROID levothyroxine sodium ADD UM: CUSTOM Must be billed with a DAW Code
of 0 08/15/2016 SYNTHROID levothyroxine sodium ADD UM: CUSTOM Must be billed
with a DAW Code of 0
08/15/2016 SYNTHROID levothyroxine sodium ADD UM: CUSTOM Must be billed with a DAW Code
of 0 08/15/2016 SYNTHROID levothyroxine sodium ADD UM: CUSTOM Must be billed
with a DAW Code of 0
08/15/2016 SYNTHROID levothyroxine sodium ADD UM: CUSTOM Must be billed with a DAW Code
of 0 08/16/2016 naloxone hcl naloxone hcl ADD TO FORMULARY Covered 08/16/2016 naloxone hcl naloxone hcl ADD TO FORMULARY Covered 08/16/2016 naloxone
hcl,naloxone naloxone hcl ADD TO FORMULARY Covered
08/16/2016 naloxone hcl,naloxone
naloxone hcl ADD UM: QUANTITY 2 / 90 days
08/16/2016 naloxone hcl naloxone hcl ADD UM: QUANTITY 2 / 90 days 08/16/2016 naloxone hcl naloxone hcl ADD UM: QUANTITY 2 / 90 days 08/16/2016 trihexyphenidyl
hcl trihexyphenidyl hcl REMOVE FROM
FORMULARY Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 133 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
08/16/2016 preplus prenatal vits with calcium no.72/ferrous fumarate/folic acid
ADD TO FORMULARY Non-Formulary Covered
08/18/2016 children's wal- zyr,cetirizine hcl,all day allergy,children's cetirizine hcl,children's allergy relief,zyrtec
cetirizine hcl REMOVE UM: AGEQUANTITY
Up to 12 yrs old; 2 / day
08/18/2016 namenda,meman tine hcl
memantine hcl CHANGE UM: QUANTITY 2 / days
08/18/2016 namenda,meman tine hcl
memantine hcl CHANGE UM: AGE Up to 64 yrs old
08/18/2016 namenda,meman tine hcl
memantine hcl ADD UM: AUTHORIZATION PA applies
08/18/2016 namenda,meman tine hcl
memantine hcl ADD TO FORMULARY Covered
08/18/2016 namenda,meman tine hcl
memantine hcl CHANGE UM: AGE Up to 64 yrs old At least 40 yrs old
08/18/2016 hydrocodone- acetaminophen,n orco,lorcet,lortab
hydrocodone bitartrate/acetaminophen,hy drocodone bit/acetaminophen
CHANGE TIER Covered
08/18/2016 hydrocodone- acetaminophen,n orco,lorcet,lortab
hydrocodone bitartrate/acetaminophen,hy drocodone bit/acetaminophen
CHANGE UM: QUANTITY 8 / days
08/18/2016 chlorhexidine gluconate
chlorhexidine gluconate CHANGE TIER Covered
08/18/2016 penlac,ciclopirox, ciclodan
ciclopirox CHANGE TIER Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 134 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
08/18/2016 all day pain relief,naproxen sodium,wal- proxen,midol,alev e,flanax,all day relief,mediproxen
naproxen sodium CHANGE UM: QUANTITY 3 / days
08/19/2016 ortho tri- cyclen,tri- sprintec,tri- previfem,tri- estarylla,tri- linyah,trinessa,no rgestimate-ethinyl estradiol
norgestimate-ethinyl estradiol
CHANGE TIER Covered
08/19/2016 ortho tri- cyclen,tri- sprintec,tri- previfem,tri- estarylla,tri- linyah,trinessa,no rgestimate-ethinyl estradiol
norgestimate-ethinyl estradiol
CHANGE UM: QUANTITY 84 / 84 days
08/19/2016 ortho tri- cyclen,tri- sprintec,tri- previfem,tri- estarylla,tri- linyah,trinessa,no rgestimate-ethinyl estradiol
norgestimate-ethinyl estradiol
CHANGE UM: GENDER Female
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 135 UPDATED 10/2018
September, 2016
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/01/2016 NICOTROL NS nicotine REMOVE UM: QUANTITY .334 / 1 days
09/01/2016 NICOTROL nicotine REMOVE UM: QUANTITY 168 / 30 days
09/01/2016 fosamax,alendro nate sodium
alendronate sodium REMOVE UM: QUANTITY .134 / 1 days
09/01/2016 valacyclovir,valtre x
valacyclovir hcl REMOVE UM: QUANTITY
09/01/2016 cholestyramine,q uestran
cholestyramine (with sugar) REMOVE UM: QUANTITY
09/01/2016 FORTEO teriparatide REMOVE UM: AUTHORIZATION
PA applies
09/01/2016 FORTEO teriparatide REMOVE UM: QUANTITY 0.034 / day
09/01/2016 albuterol sulfate,accuneb
albuterol sulfate REMOVE UM: QUANTITY 22.5 / 1 days
09/01/2016 albuterol sulfate,accuneb
albuterol sulfate REMOVE UM: QUANTITY 22.5 / 1 days
09/01/2016 ortho evra,xulane norelgestromin/ethinyl estradiol
REMOVE UM: QUANTITY
09/01/2016 cormax,clobetaso l propionate,temov ate
clobetasol propionate REMOVE UM: AUTHORIZATION
PA applies
09/01/2016 cormax,clobetaso l propionate,temov ate
clobetasol propionate REMOVE UM: QUANTITY 1.67 / day
09/01/2016 AVONEX interferon beta-1a/albumin human
REMOVE UM: QUANTITY 0.04 / day
09/01/2016 NUVARING etonogestrel/ethinyl estradiol REMOVE UM: QUANTITY 1 / 28 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 136 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/01/2016 HUMIRA,HUMIR A PEDIATRIC CROHN'S
adalimumab REMOVE UM: QUANTITY
09/01/2016 EPIPEN JR,EPIPEN JR 2- PAK
epinephrine REMOVE UM: QUANTITY .0667 / 1 days
09/01/2016 auvi- q,epinephrine,epi pen,epipen 2- pak,adrenaclick
epinephrine REMOVE UM: QUANTITY .0667 / 1 days
09/01/2016 AVONEX interferon beta-1a REMOVE UM: AUTHORIZATION
PA applies
09/01/2016 AVONEX interferon beta-1a REMOVE UM: QUANTITY 0.143 / day
09/01/2016 AVONEX interferon beta-1a REMOVE UM: QUANTITY 0.143 / day
09/01/2016 proventil hfa,ventolin hfa,proair hfa,albuterol sulfate hfa
albuterol sulfate REMOVE UM: QUANTITY 18 / 30 days
09/01/2016 chlorhexidine gluconate,periog ard,peridex,paroe x,perisol
chlorhexidine gluconate REMOVE UM: QUANTITY
09/01/2016 miacalcin,fortical, calcitonin-salmon
calcitonin,salmon,synthetic REMOVE UM: QUANTITY 0.107 / day
09/01/2016 ENBREL etanercept REMOVE UM: AUTHORIZATION
PA applies
09/01/2016 ENBREL etanercept REMOVE UM: QUANTITY 0.14 / Day
09/01/2016 ATROVENT HFA ipratropium bromide REMOVE UM: QUANTITY 0.43 / day
09/01/2016 VICTOZA 2- PAK,VICTOZA 3- PAK
liraglutide REMOVE UM: AUTHORIZATION
PA applies
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 137 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/01/2016 VICTOZA 2- PAK,VICTOZA 3- PAK
liraglutide REMOVE UM: QUANTITY 9 / 30 DAYS
09/01/2016 cetirizine hcl cetirizine hcl REMOVE UM: QUANTITY 1 / Day
09/01/2016 auvi- q,adrenaclick,epi nephrine
epinephrine REMOVE UM: QUANTITY .0667 / days
09/01/2016 DULERA mometasone furoate/formoterol fumarate
REMOVE UM: QUANTITY .433 / 1 days
09/01/2016 DULERA mometasone furoate/formoterol fumarate
REMOVE UM: QUANTITY .433 / 1 days
09/01/2016 vivelle- dot,estraderm,alo ra,vivelle,minivell e,estradiol
estradiol REMOVE UM: QUANTITY .286 / 1 days
09/01/2016 vivelle- dot,estraderm,alo ra,vivelle,minivell e,estradiol
estradiol REMOVE UM: QUANTITY .286 / 1 days
09/01/2016 estradiol,climara, estradiol transdermal patch
estradiol REMOVE UM: QUANTITY .143 / 1 days
09/01/2016 estradiol,climara estradiol REMOVE UM: QUANTITY .143 / 1 days
09/01/2016 estradiol,climara estradiol REMOVE UM: QUANTITY .154 / 1 days
09/01/2016 AVONEX PEN interferon beta-1a REMOVE UM: AUTHORIZATION
PA applies
09/01/2016 AVONEX PEN interferon beta-1a REMOVE UM: QUANTITY 0.143 / day
09/01/2016 COMBIVENT RESPIMAT
ipratropium bromide/albuterol sulfate
REMOVE UM: QUANTITY 0.267 / day
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 138 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/01/2016 xalatan,latanopro st
latanoprost REMOVE UM: QUANTITY
09/01/2016 AEROSPAN flunisolide REMOVE UM: QUANTITY
09/01/2016 nasacort,children' s nasacort,nasal allergy,triamcinol one acetonide
triamcinolone acetonide REMOVE UM: QUANTITY
09/01/2016 HUMIRA adalimumab REMOVE UM: QUANTITY 0.08 / Day
09/01/2016 bactroban,mupiro cin,centany
mupirocin,mupirocin calcium REMOVE UM: QUANTITY
09/01/2016 cetirizine hcl,children's all day allergy,children's wal-zyr,wal- zyr,children's zyrtec,all day allergy,children's allergy relief,children's cetirizine hcl,children's allergy,children's allergy complete,children 's aller- tec,children's zyrtec hives relief,zyrtec,allerg y relief
cetirizine hcl ADD UM: AGE Up to 12 yrs old
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 139 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/01/2016 cetirizine hcl,children's all day allergy,children's wal-zyr,wal- zyr,children's zyrtec,all day allergy,children's allergy relief,children's cetirizine hcl,children's allergy,children's allergy complete,children 's aller- tec,children's zyrtec hives relief,zyrtec,allerg y relief
cetirizine hcl REMOVE UM: AGEQUANTITY
09/01/2016 ENBREL etanercept REMOVE UM: AUTHORIZATION
PA applies
09/01/2016 ENBREL etanercept REMOVE UM: QUANTITY 0.27 / Day
09/01/2016 ESTRACE estradiol REMOVE UM: QUANTITY 1.42 / day
09/01/2016 QVAR beclomethasone dipropionate
REMOVE UM: QUANTITY 0.29 / day
09/01/2016 QVAR beclomethasone dipropionate
REMOVE UM: QUANTITY 0.29 / day
09/01/2016 fosamax,alendro nate sodium
alendronate sodium REMOVE UM: QUANTITY
09/01/2016 benzamycin,eryth romycin-benzoyl peroxide
erythromycin base/benzoyl peroxide
REMOVE UM: QUANTITY 1.554 / days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 140 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/01/2016 clearlax,smoothla x,polyethylene glycol 3350,miralax,laxa tive peg 3350,gavilax,pure lax,healthylax
polyethylene glycol 3350 REMOVE UM: QUANTITY 17 / day
09/01/2016 RELENZA zanamivir REMOVE UM: QUANTITY 0.0556 / Day
09/01/2016 HUMIRA PEN,HUMIRA PEN CROHN- UC-HS STARTER,HUMI RA PEN PSORIASIS- UVEITIS
adalimumab REMOVE UM: QUANTITY
09/01/2016 ENBREL SURECLICK
etanercept REMOVE UM: AUTHORIZATION
PA applies
09/01/2016 ENBREL SURECLICK
etanercept REMOVE UM: QUANTITY 0.14 / Day
09/01/2016 ENBREL etanercept REMOVE UM: AUTHORIZATION
PA applies
09/01/2016 ENBREL etanercept REMOVE UM: QUANTITY 0.16 / Day
09/01/2016 SYMBICORT budesonide/formoterol fumarate
REMOVE UM: QUANTITY 0.34 / day
09/01/2016 SYMBICORT budesonide/formoterol fumarate
REMOVE UM: QUANTITY 0.34 / day
09/01/2016 cholestyramine light,prevalite,que stran light
cholestyramine/aspartame REMOVE UM: QUANTITY
09/01/2016 SPIRIVA RESPIMAT
tiotropium bromide REMOVE UM: QUANTITY 0.134 / days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 141 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/01/2016 HUMIRA adalimumab REMOVE UM: QUANTITY 0.08 / Day
09/01/2016 AEROSPAN flunisolide ADD UM: QUANTITY 8.9 / 30 days 09/01/2016 AEROSPAN flunisolide CHANGE UM: QUANTITY 0.6 / day 8.9 / 30 days 09/01/2016 albuterol
sulfate,accuneb albuterol sulfate CHANGE UM: QUANTITY 22.5 / 1 days 225 / 30 days
09/01/2016 albuterol sulfate,accuneb
albuterol sulfate CHANGE UM: QUANTITY 22.5 / 1 days 225 / 30 days
09/01/2016 alendronate sodium
alendronate sodium CHANGE UM: QUANTITY .134 / 1 days 4 / 28 days
09/01/2016 FOSAMAX alendronate sodium CHANGE UM: QUANTITY 0.133 / day 4 / 28 days 09/01/2016 alendronate
sodium alendronate sodium CHANGE UM: QUANTITY .134 / 1 days 4 / 28 days
09/01/2016 ATROVENT HFA ipratropium bromide CHANGE UM: QUANTITY 0.43 / day 12.9 / 30 days 09/01/2016 AVONEX interferon beta-1a/albumin
human CHANGE UM: QUANTITY 0.04 / day 1 / 28 days
09/01/2016 AVONEX PEN interferon beta-1a CHANGE UM: QUANTITY 0.143 / day 4 / 28 days 09/01/2016 AVONEX interferon beta-1a CHANGE UM: QUANTITY 0.143 / day 4 / 28 days 09/01/2016 AVONEX interferon beta-1a CHANGE UM: QUANTITY 0.143 / day 4 / 28 days 09/01/2016 betamethasone
diprop augmented,diprol ene af,betamethason e dipropionate
betamethasone dipropionate/propylene glycol
ADD UM: QUANTITY 50 / 30 days
09/01/2016 betamethasone diprop augmented,beta methasone dipropionate
betamethasone dipropionate ADD UM: QUANTITY 50 / 30 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 142 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/01/2016 betamethasone diprop augmented,diprol ene
betamethasone dipropionate/propylene glycol
ADD UM: QUANTITY 60 / 30 Days
09/01/2016 betamethasone diprop augmented,diprol ene,betamethaso ne dipropionate
betamethasone dipropionate/propylene glycol
ADD UM: QUANTITY 50 / 30 days
09/01/2016 calcitonin- salmon,fortical,mi acalcin
calcitonin,salmon,synthetic CHANGE UM: QUANTITY 0.107 / day 3.7 / 30 days
09/01/2016 cetirizine hcl,children's all day allergy,children's wal-zyr,children's allergy relief,children's cetirizine hcl,children's allergy complete,wal- zyr,zyrtec,childre n's aller- tec,allergy relief,children's zyrtec hives relief,children's allergy,children's zyrtec,all day allergy
cetirizine hcl ADD UM: QUANTITY 300 / 30 days
09/01/2016 cetirizine hcl cetirizine hcl CHANGE UM: QUANTITY 1 / Day 300 / 30 days 09/01/2016 chlorhexidine
gluconate chlorhexidine gluconate ADD UM: QUANTITY 480 / 30 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 143 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/01/2016 peridex,chlorhexi dine gluconate,periog ard,paroex,periso l
chlorhexidine gluconate CHANGE UM: QUANTITY 16 / 1 days 480 / 30 days
09/01/2016 cholestyramine light,prevalite,que stran light
cholestyramine/aspartame CHANGE UM: QUANTITY 1 / Day 239.4 / 30 days
09/01/2016 cholestyramine light,prevalite,que stran light
cholestyramine/aspartame CHANGE UM: QUANTITY 1 / Day 240 / 30 days
09/01/2016 cholestyramine,q uestran
cholestyramine (with sugar) CHANGE UM: QUANTITY 1 / Day 378 / 30 days
09/01/2016 cormax,clobetaso l propionate,temov ate
clobetasol propionate CHANGE UM: QUANTITY 1.67 / day 50 / 30 days
09/01/2016 COMBIVENT RESPIMAT
ipratropium bromide/albuterol sulfate
CHANGE UM: QUANTITY 0.267 / day 4 / 30 days
09/01/2016 DULERA mometasone furoate/formoterol fumarate
CHANGE UM: QUANTITY .433 / 1 days 13 / 30 days
09/01/2016 DULERA mometasone furoate/formoterol fumarate
CHANGE UM: QUANTITY .433 / 1 days 13 / 30 days
09/01/2016 ENBREL etanercept CHANGE UM: QUANTITY 0.27 / Day 4 / 28 days 09/01/2016 ENBREL etanercept CHANGE UM: QUANTITY 0.16 / Day 2.04 / 28 days 09/01/2016 ENBREL
SURECLICK etanercept CHANGE UM: QUANTITY 0.14 / Day 3.92 / 28 days
09/01/2016 ENBREL etanercept CHANGE UM: QUANTITY 0.14 / Day 3.92 / 28 days 09/01/2016 epinephrine,auvi-
q,adrenaclick epinephrine CHANGE UM: QUANTITY .0667 / days 2 / 30 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 144 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/01/2016 epipen,epinephri ne,auvi-q,epipen 2-pak,adrenaclick
epinephrine CHANGE UM: QUANTITY .0667 / 1 days 2 / 30 days
09/01/2016 EPIPEN JR,EPIPEN JR 2- PAK
epinephrine CHANGE UM: QUANTITY .0667 / 1 days 2 / 30 days
09/01/2016 erythromycin- benzoyl peroxide,benzam ycin
erythromycin base/benzoyl peroxide
CHANGE UM: QUANTITY 1.554 / days 46.6 / 30 days
09/01/2016 ESTRACE estradiol CHANGE UM: QUANTITY 1.42 / day 42.5 / 30 days 09/01/2016 climara,estradiol estradiol CHANGE UM: QUANTITY .143 / 1 days 4 / 28 days 09/01/2016 vivelle-
dot,vivelle,estrad erm,estradiol,mini velle,alora
estradiol CHANGE UM: QUANTITY .286 / 1 days 8 / 28 days
09/01/2016 climara,estradiol, estradiol transdermal patch
estradiol CHANGE UM: QUANTITY .143 / 1 days 4 / 28 days
09/01/2016 vivelle- dot,estradiol,mini velle,alora
estradiol CHANGE UM: QUANTITY .286 / 1 days 8 / 28 days
09/01/2016 climara,estradiol estradiol CHANGE UM: QUANTITY .154 / 1 days 4 / 28 days 09/01/2016 vivelle,vivelle-
dot,estradiol,estr aderm,minivelle,a lora
estradiol CHANGE UM: QUANTITY .286 / 1 days 8 / 28 days
09/01/2016 estradiol transdermal patch,estradiol,cli mara
estradiol CHANGE UM: QUANTITY .143 / 1 days 4 / 28 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 145 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/01/2016 fluorometholone,f ml
fluorometholone CHANGE UM: QUANTITY 5 / Day 15 / 30 days
09/01/2016 FORTEO teriparatide CHANGE UM: QUANTITY 0.034 / Day 2.4 / 30 days 09/01/2016 ultravate,halobet
asol propionate halobetasol propionate ADD UM: QUANTITY 50 / 30 days
09/01/2016 halobetasol propionate,ultrav ate
halobetasol propionate ADD UM: QUANTITY 50 / 30 days
09/01/2016 HUMIRA adalimumab CHANGE UM: QUANTITY 0.08 / Day 2 / 28 days 09/01/2016 HUMIRA adalimumab CHANGE UM: QUANTITY 0.08 / Day 2 / 28 days 09/01/2016 HUMIRA
PEN,HUMIRA PEN CROHN- UC-HS STARTER,HUMI RA PEN PSORIASIS- UVEITIS
adalimumab CHANGE UM: QUANTITY 0.15 / Day 4 / 28 days
09/01/2016 HUMIRA,HUMIR A PEDIATRIC CROHN'S
adalimumab ADD UM: QUANTITY 0.15 / Day
09/01/2016 HUMIRA PEN CROHN-UC-HS STARTER
adalimumab CHANGE UM: QUANTITY 0.15 / Day 4 / 28 days
09/01/2016 hydrocodone- acetaminophen
hydrocodone bitartrate/acetaminophen
CHANGE UM: QUANTITY 60 / days 480 / 28 days
09/01/2016 XALATAN latanoprost ADD UM: QUANTITY 2.5 / 30 days 09/01/2016 mupirocin mupirocin ADD UM: QUANTITY 22 / 30 days 09/01/2016 mupirocin,bactro
ban,centany mupirocin,mupirocin calcium CHANGE UM: QUANTITY 0.075 / day 22 / 30 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 146 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/01/2016 triamcinolone acetonide,nasal allergy
triamcinolone acetonide ADD UM: QUANTITY 16.9 / 30 days
09/01/2016 children's nasacort,nasacor t,nasal allergy
triamcinolone acetonide CHANGE UM: QUANTITY 0.564 / 1 days 16.9 / 30 days
09/01/2016 NICOTROL NS nicotine CHANGE UM: QUANTITY .334 / 1 days 40 / 30 days 09/01/2016 NUVARING etonogestrel/ethinyl estradiol CHANGE UM: QUANTITY 1 / 28 days 3 / 84 days 09/01/2016 polyethylene
glycol 3350,smoothlax, miralax,healthyla x,purelax
polyethylene glycol 3350 CHANGE UM: QUANTITY 17 / day 30 / 30 days
09/01/2016 QVAR beclomethasone dipropionate
CHANGE UM: QUANTITY 0.29 / day 8.7 / 30 days
09/01/2016 QVAR beclomethasone dipropionate
CHANGE UM: QUANTITY 0.29 / day 8.7 / 30 days
09/01/2016 RELENZA zanamivir CHANGE UM: QUANTITY 0.0556 / Day 20 / 180 days 09/01/2016 SANTYL collagenase clostridium
histolyticum ADD UM: QUANTITY 60 / 30 Days
09/01/2016 SPIRIVA RESPIMAT
tiotropium bromide CHANGE UM: QUANTITY 0.134 / days 4 / 30 days
09/01/2016 SYMBICORT budesonide/formoterol fumarate
CHANGE UM: QUANTITY 0.34 / day 10.2 / 30 days
09/01/2016 SYMBICORT budesonide/formoterol fumarate
CHANGE UM: QUANTITY 0.34 / day 10.2 / 30 days
09/01/2016 travoprost travoprost (benzalkonium) ADD UM: QUANTITY 5 / 30 days 09/01/2016 valacyclovir,valtre
x valacyclovir hcl CHANGE UM: QUANTITY 2 / Day 30 / 30 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 147 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/01/2016 proair hfa,proventil hfa,ventolin hfa,albuterol sulfate hfa
albuterol sulfate CHANGE UM: QUANTITY 18 / 30 days 18 / 25 days
09/01/2016 VICTOZA 3- PAK,VICTOZA 2- PAK
liraglutide CHANGE UM: QUANTITY 9 / 30 DAYS 6 / 30 days
09/01/2016 xulane norelgestromin/ethinyl estradiol
CHANGE UM: QUANTITY 0.14286 / Day 9 / 84 days
09/01/2016 ORTHO EVRA norelgestromin/ethinyl estradiol
CHANGE UM: QUANTITY 0.143 / day 9 / 84 days
09/08/2016 HUMIRA,HUMIR A PEDIATRIC CROHN'S
adalimumab ADD UM: AUTHORIZATION PA applies
09/08/2016 HUMIRA,HUMIR A PEDIATRIC CROHN'S
adalimumab ADD UM: QUANTITY 4 / 28 days
09/08/2016 niaspan,niacin er niacin CHANGE UM: QUANTITY 4 / days 09/08/2016 lidocaine lidocaine CHANGE UM: QUANTITY 1 / days 09/08/2016 copaxone,glatopa glatiramer acetate ADD UM: QUANTITY 1 / days 09/12/2016 xalatan,latanopro
st latanoprost CHANGE UM: QUANTITY 2.5 / 30 days
09/12/2016 diskets,methados e,methadone hcl
methadone hcl CHANGE UM: QUANTITY 3 / days
09/12/2016 femhrt,norethindr on-ethinyl estradiol,jevantiq ue lo,fyavolv
norethindrone acetate- ethinyl estradiol
CHANGE UM: QUANTITY 1 / days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 148 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/12/2016 femhrt,norethindr on-ethinyl estradiol,jevantiq ue lo,fyavolv
norethindrone acetate- ethinyl estradiol
CHANGE UM: GENDER Female
09/12/2016 tylenol extra strength,pain relief extra strength,pain relief,genebs,acet aminophen,pain reliever,pain & fever,q-pap extra strength,mapap,n on-aspirin extra strength,acetami nophen extra strength,masoph en,extra strength non- aspirin,pharbetol, acetaminophen pain relief,non- aspirin pain relief,aspirin free,medi- tabs,medi-tabs extra strength,pain relief cool ice,tylenol extra strength arthrit,tactinal,ace taminophen es,maxapap,gen apap,pain reliver super strength,shake that ache
acetaminophen,aspirin REMOVE UM: QUANTITY
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 149 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/12/2016 estradiol,climara estradiol CHANGE UM: QUANTITY 0.133 / day 4 / 28 days 09/12/2016 estradiol,climara estradiol CHANGE UM: QUANTITY .143 / 1 days 4 / 28 days 09/12/2016 vivelle-
dot,estradiol,alor a,minivelle
estradiol CHANGE UM: QUANTITY .286 / 1 days 8 / 28 days
09/12/2016 vivelle- dot,minivelle,estr adiol
estradiol CHANGE UM: QUANTITY .286 / 1 days 8 / 28 days
09/13/2016 ASACOL HD mesalamine REMOVE FROM FORMULARY
Covered Non-Formulary
09/13/2016 NILANDRON nilutamide REMOVE FROM FORMULARY
Covered Non-Formulary
09/14/2016 nilutamide nilutamide ADD TO FORMULARY Covered 09/14/2016 nilutamide nilutamide ADD UM: AUTHORIZATION PA applies 09/14/2016 NILANDRON nilutamide REMOVE UM:
AUTHORIZATION PA applies
09/14/2016 mesalamine mesalamine ADD TO FORMULARY Covered 09/14/2016 mesalamine mesalamine ADD UM: QUANTITY 6 / days 09/14/2016 hycet,hydrocodon
e-acetaminophen hydrocodone bitartrate/acetaminophen
CHANGE UM: QUANTITY 60 / days 480 / 28 days
09/14/2016 APIDRA insulin glulisine ADD UM: QUANTITY 2 / days 09/14/2016 APIDRA,APIDRA
SOLOSTAR insulin glulisine ADD UM: QUANTITY 2 / days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 150 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/14/2016 children's tylenol,tylenol,inf ants' tylenol,children's pain relief,children's pain-fever,infants' pain- fever,children's non- aspirin,children's q- pap,mapap,infant s' mapap,children's pain reliever,infants' pain reliever,acetamin ophen,children's acetaminophen,f ever reducer-pain reliever,non- aspirin,infant fever-pain reliever,childrens suspension,pedia care fever reducer,infant's pain relief,infants' pain relief,infant pain-fever,infants' acetaminophen,c hild's accudial acetaminophen,in fant pain relief,children's medi- tabs,betatemp,littl
acetaminophen REMOVE UM: QUANTITY
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 151 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
e remedies fever- pain,nortemp
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 152 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/14/2016 children's tylenol,tylenol,inf ants' tylenol,children's pain relief,children's pain-fever,infants' pain- fever,children's non- aspirin,children's q- pap,mapap,infant s' mapap,children's pain reliever,infants' pain reliever,acetamin ophen,children's acetaminophen,f ever reducer-pain reliever,non- aspirin,infant fever-pain reliever,childrens suspension,pedia care fever reducer,infant's pain relief,infants' pain relief,infant pain-fever,infants' acetaminophen,c hild's accudial acetaminophen,in fant pain relief,children's medi- tabs,betatemp,littl
acetaminophen ADD UM: QUANTITY 125 / days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 153 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
e remedies fever- pain,nortemp
09/14/2016 bisoprolol- hydrochlorothiazi de,ziac,bisoprolol fumarate-hctz
bisoprolol fumarate/hydrochlorothiazid e
CHANGE UM: QUANTITY 60 / 30 days
09/14/2016 nilandron,nilutami de
nilutamide CHANGE UM: AUTHORIZATION
PA applies
09/14/2016 octreotide acetate
octreotide acetate ADD UM: AUTHORIZATION PA applies
09/15/2016 oyster shell calcium w-vit d
calcium carbonate/ergocalciferol (vitamin d2)
REMOVE UM: CUSTOM Covered for CSHCS Only
09/15/2016 tri-vitamin with fluoride,tri- vitamins with fluoride
pediatric multivit with a,c,d3 no.21/sodium fluoride,pediatric multivitamins a,c,& d3 no.21 with sodium fluoride,fluoride/vitamins a,c,and d
ADD TO FORMULARY Covered
09/15/2016 calciferol ergocalciferol (vitamin d2) ADD TO FORMULARY Covered 09/15/2016 ergocalciferol ergocalciferol (vitamin d2) ADD TO FORMULARY Covered 09/15/2016 DRISDOL ergocalciferol (vitamin d2) ADD TO FORMULARY Covered 09/16/2016 calciferol ergocalciferol (vitamin d2) REMOVE FROM
FORMULARY Covered Non-Formulary
09/16/2016 ergocalciferol ergocalciferol (vitamin d2) REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 nitroglycerin nitroglycerin ADD TO FORMULARY Covered 09/19/2016 nitroglycerin nitroglycerin CHANGE TIER Covered 09/19/2016 CREON lipase/protease/amylase ADD UM: QUANTITY 168 / days 09/19/2016 CREON lipase/protease/amylase ADD UM: QUANTITY 90 / days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 154 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/19/2016 CREON lipase/protease/amylase ADD UM: QUANTITY 42 / days 09/19/2016 tizanidine
hcl,zanaflex tizanidine hcl ADD TO FORMULARY Non-Formulary Covered
09/19/2016 tizanidine hcl,zanaflex
tizanidine hcl ADD TO FORMULARY Non-Formulary Covered
09/19/2016 pyridostigmine bromide
pyridostigmine bromide ADD TO FORMULARY Covered
09/19/2016 NARCAN naloxone hcl ADD TO FORMULARY Covered 09/19/2016 autoshield pen
needle pen needle, diabetic, safety ADD TO FORMULARY Covered
09/19/2016 autoshield pen needle
pen needle, diabetic, safety ADD TO FORMULARY Covered
09/19/2016 morphine sulfate morphine sulfate REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 potassium acetate
potassium acetate REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 potassium acetate
potassium acetate REMOVE UM: QUANTITY 3 / Day
09/19/2016 potassium bicarbonate
potassium bicarbonate REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 potassium bicarbonate
potassium bicarbonate REMOVE UM: QUANTITY 3 / Day
09/19/2016 CALCI-MIX calcium carbonate REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 calci- chew,calcium,cal cium carbonate
calcium carbonate REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 calcium chloride calcium chloride REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 155 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/19/2016 calcium chloride calcium chloride REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 calcium gluconate
calcium gluconate REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 calcium gluconate
calcium gluconate REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 calcium lactate calcium lactate REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 infed,iron dextran complex
iron dextran complex REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 hemocyte ferrous fumarate REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 nu-iron 150,polysacchari de iron 150,ferrex 150,polysacchari de iron,ferus,myfero n 150,poly- iron,iferex 150,altorex,ferric
150
iron polysaccharide complex,iron polysaccharides complex
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 iron ferrous sulfate REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 iron iron REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 titralac,alcalak,an tacid
calcium carbonate REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 156 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/19/2016 children's soothe,children's pepto,childrens maalox,children's mylanta,childrens calcium antacid
calcium carbonate REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 milk of magnesia magnesium hydroxide CHANGE TIER Covered 09/19/2016 phillips' milk of
magnesia,magne sia,phillips'
magnesium hydroxide REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 aluminum hydroxide,alterna gel
aluminum hydroxide REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 ron-acid,ri-mag magaldrate REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 equalactin calcium polycarbophil REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 bisacodyl bisacodyl REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 adult glycerin,sani- supp,glycerin,sup pository,colace
glycerin REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 pedia-lax,sani- supp,glycerin,lax ative suppository,infant glycerin,child suppository,colac e
glycerin REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 castor oil castor oil REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 157 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/19/2016 mineral oil,mineral oil extra heavy
mineral oil REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 docusate sodium,diocto,do c-q-lace,stool softener,dioctyl,si lace,colace
docusate sodium REMOVE FROM FORMULARY
Non-Formulary
09/19/2016 pedia-lax stool softener
docusate sodium REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 epsom salt magnesium sulfate REMOVE FROM FORMULARY
Non-Formulary
09/19/2016 CITROMA magnesium citrate REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 hydrocil instant,natural fiber
psyllium seed REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 citrucel,fiber therapy,soluble fiber
methylcellulose REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 citrucel,fiber therapy,fiber laxative,soluble fiber,fiber
methylcellulose REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 corlopam,fenoldo pam mesylate
fenoldopam mesylate REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 KRISTALOSE lactulose REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 158 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/19/2016 polysaccharide iron forte,ferrex 150 forte,niferex- 150 forte,myferon-150 forte,poly-iron 150 forte,iferex 150 forte
iron polysaccharide complex/cyanocobalamin/fol ic acid,iron polysaccharides complex/cyanocobalamin/fol ic acid,iron bisgly & ps cmplx/ascorbate ca/b12/folic acid/ca-threo
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 docusol docusate sodium REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 KRISTALOSE lactulose REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 ex-lax,chocolated laxative,laxative
sennosides REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 OSMOPREP sodium phosphate,monobasic/sodiu m phosphate,dibasic,sodium phosphate,m-basic m- hyd/sodium phosphate,dibasic
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 PROFERRIN iron heme polypeptide REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 FERRIMIN 150 ferrous fumarate REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 VITAFOL ferrous fumarate/calcium/vitamin e/folic acid/multivitamin
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 centratex,hemocy te plus,reocyte plus,ferrocite plus
ferrous fumarate/folic acid/multivitamin-minerals no.15,ferrous fumarate/folic acid/multivitamins with min no. 15
REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 159 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/19/2016 benefiber,fiber,nu trisource fiber,easy fiber
guar gum REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 BENEFIBER,NU TRISOURCE FIBER
guar gum REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 calcium 600 + vit d,liquid calcium 600-vit d3
calcium carbonate/cholecalciferol (vitamin d3)
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 maalox,maalox advanced,antacid -antigas,maalox quick dissolve
calcium carbonate/simethicone,calci um carbonate
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 LYDIA PINKHAM HERBAL
ferrous sulfate/licorice root extract
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 fiber,easy fiber dextrin,psyllium seed (with dextrose)
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 RIGINIC magnesium carbonate/aluminum hydroxide/alginic acid
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 ZEMPLAR paricalcitol REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 hematron-af,tl- hem 150,hemax
iron,carbonyl/docusate sodium/b12-if/folic acid/multivit- min,iron,carbonyl/methylfolat e/vit c/vit e/vit b12/biotin/copper
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 calcium- magnesium
calcium/magnesium REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 LIFE-PACK multivitamin with iron and other minerals
REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 160 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/19/2016 LIFE-PACK bioflavonoids/multivitamin with iron and other minerals
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 viactiv,calcium-vit d3-vit k
calcium carbonate/cholecalciferol (vit d3)/phytonadione,calcium carbonate/cholecalciferol (vit d3)/vit k1
REMOVE FROM FORMULARY
Non-Formulary
09/19/2016 hectorol,doxercal ciferol
doxercalciferol REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 bifera,feosol,duof er
iron polysaccharide complex/iron heme polypeptide
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 PROFERRIN- FORTE
iron heme polypeptide/folic acid
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 feosol,iron iron,carbonyl REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 soy formula calcium carbonate/cholecalciferol (vit d3)/soybean
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 CORAL CALCIUM
calcium/magnesium oxide/cholecalciferol (vitamin d3)
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 fatigue relief complex
vitamin b comp and c/st.jhn wrt/siberian ginseng/p.ginsg
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 konsyl,wal- mucil,reguloid,fib er laxative,psyllium fiber,fiber,natural fiber,metamucil,m edi-mucil,fiber therapy,daily fiber,genfiber
psyllium husk REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 161 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/19/2016 folgard os,tl g-fol os
calcium carb/mag oxide/vitamin d3/vit b12/fa/vit b6/boron
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 PRELIEF calcium glycerophosphate REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 UNIFIBER cellulose REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 coral calcium calcium carbonate/magnesium/chole calciferol (vit d3)
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 coral calcium calcium carbonate/magnesium oxide/cholecalciferol (vit d3)
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 DIALYVITE 800 WITH IRON
ferrous fumarate/folic acid/vitamin b comp and c
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 ferrous gluconate ferrous gluconate REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 calcium gluconate
calcium gluconate REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 citrus calcium- vitamin d3,calcium citrate-vit d3,citracal- vitamin d3,citracal- vitamin d
calcium citrate/cholecalciferol (vitamin d3)
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 CITRACAL + BONE DENSITY
calcium carb,citrate/vitamin d3/mineral comb no.34/genistein
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 LIQUAFIBER glycerin/maltodextrin REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 162 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/19/2016 folivane- plus,integra plus
iron fumarate,polysac cplex/folic acid/vitb comp with c no.9
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 INTEGRA iron fumarate/iron polysac complex/vitamin c/niacinamide
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 folivane-f,integra f
iron fumarate,polysac comp/folic acid/vitamin c/niacinamide
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 MAGNEBIND 300
calcium carbonate/magnesium carbonate
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 hectorol,doxercal ciferol
doxercalciferol REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 antacid multi- symptom,rolaids,r olaids multi- symptom
calcium carbonate/magnesium hydroxide/simethicone
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 rolaids extra strength,antacid, antacid extra strength
calcium carbonate/magnesium hydroxide
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 HECTOROL doxercalciferol REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 antacid ultra strength,rolaids extra strength,tums ultra strength
calcium carbonate REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 bone density calcium + d
calcium carbonate/vitamin d3/arginine/inositol/silicon
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 FERRETTS IPS iron succinyl-protein complex
REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 163 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/19/2016 DIABETES HEALTH
alpha lipoic acid/folic acid/multivit with minerals/lutein
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 WOMEN'S PACK,MEN'S PACK
folic acid/multivitamin w- minerals/lutein,folic acid/multivit with minerals/lutein
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 MAXIMIN folic acid/multivit with minerals/lutein
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 SENNA senna leaf extract REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 calcium- magnesium-zinc
calcium/magnesium/zinc REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 APETIGEN- PLUS
ferrous gluconate/lysine hcl/vit e/vit b cplex with c/zinc
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 calcium citrate- vitamin d
calcium citrate/cholecalciferol (vitamin d3)
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 ezfe 200,pic 200 iron polysaccharide complex REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 zemplar,paricalcit ol
paricalcitol REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 zemplar,paricalcit ol
paricalcitol REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 zemplar,paricalcit ol
paricalcitol REMOVE FROM FORMULARY
Non-Formulary
09/19/2016 corvita,corvite folic acid/multivitamin,ther and minerals/lycopene/lutein
REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 164 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/19/2016 ICAPS,CARDIOT EK
riboflavin/beta-carotene(a) w-c and e/lutein/zeaxanthin/min,vit c/vite ac/pyridox hcl/fa/vit b12/arginine hcl/pepper ext,riboflavin/beta- carotene(a) w-c & e/lutein/zeaxanthin/min
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 dical-d,calvite p&d,risacal-d
calcium phosphate, dibasic/cholecalciferol (vitamin d3)
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 wal-mucil plus calcium,wal- mucil,metamucil plus calcium,fiber plus calcium
psyllium husk/calcium carbonate
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 calcium carbonate
calcium carbonate REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 SENNA PROMPT
sennosides/psyllium husk,sennosides/psyllium
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 advanced am/pm,encora
omega-3/calcium carbonate/vit d3/folic acid/multivit no.13,omega-3 fatty acids/ca carbonate/vitamin d3/fa/mv cmb 13
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 FIBER-STAT fructooligosaccharides/malto dextrin
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 viactiv,calcium soft chew,calcium,soft chews calcium
calcium carbonate/cholecalciferol (vit d3)/phytonadione,calcium carbonate/cholecalciferol (vit d3)/vit k1
REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 165 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/19/2016 calcium 500 + vit d
calcium carbonate/cholecalciferol (vitamin d3)
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 calcium citrate malate with d
calcium citrate malate/cholecalciferol (vitamin d3)
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 weight management fiber,fiber,fiber supplement
inulin/sorbitol REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 TANDEM DUAL ACTION
ferrous fumarate/iron polysaccharide complex
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 FERAHEME ferumoxytol REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 CALCIONATE calcium glubionate REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 se-tan plus,tandem plus,dualvit plus,purevit dualfe plus
iron fumarate-iron polysacch cplex/folic acid/multivit no.18,iron fumarate-iron polysacchar/folic acid/mv comb18
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 hectorol,doxercal ciferol
doxercalciferol REMOVE FROM FORMULARY
Non-Formulary
09/19/2016 children's benefiber,benefib er,natural fiber,total fiber,best fiber
wheat dextrin REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 calcium citrate- vitamin d,citracal- vitamin d,calcium citrate-vitamin d3
calcium citrate/cholecalciferol (vitamin d3)
REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 166 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/19/2016 metamucil fiber singles,natural fiber supplement
psyllium husk/aspartame REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 FEM-CAL CITRATE
calcium citrate/magnesium ox/vit d2/manganese/boron/silica
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 GAVISCON magnesium trisilicate/aluminum hydrox/sod bicarb/alginic ac,magnesium trisilicate/al hydrox/sod bicarb/alginic acid
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 OSTEO- PORETICAL
calcium carbonate/cholecalciferol (vitamin d3)
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 SUPERVITE EC multivitamin-minerals no.21/folic acid,folic acid/multivitamin w-minerals
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 CALCET calcium citrate/cholecalciferol (vitamin d3)
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 acetaminophen, mapap
acetaminophen REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 acetaminophen, mapap
acetaminophen REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 CITRACAL-VIT D + MAGNESIUM,CI TRACAL
calcium cit/magnesium/d3/zinc ox/copper gluc/manganese/boron,calci um citrate/magnesium oxide/vitamin d3/pyridoxine/min
REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 167 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/19/2016 FERRACTIV IRON
iron amino acid chelate/cyanocobalamin/foli c acid
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 PEDIA-LAX glycerin REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 PEDIA-LAX magnesium hydroxide REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 CITRACAL D + HEART HEALTH
calcium carbonate and citrate/vitamin d3/phytosterol
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 calcium lactate calcium lactate REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 calcium gluconate
calcium gluconate REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 DEWEE'S CARMINATIVE
magnesium carbonate/asafetida
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 calcium citrate calcium citrate REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 PARVA-CAL 500 calcium carbonate,calcium gluconate/ergocalciferol (vit d2)
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 centrum,cerovite, certavite- antioxidant,multiv itamins with minerals,centami n,centram-care
multivitamin with minerals/ferrous gluconate
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 calcium carbonate
calcium carbonate REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 ferrous fumarate ferrous fumarate REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 168 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/19/2016 ferralet 90,natalvirt flt,fe 90 plus,focalgin dss
iron carbonyl,gluc/folic acid/vit b12/vit c/docusate sodium,iron,carbonyl/folic acid/vitamin b12/vitamin c/docusate na
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 bifera rx,hemetab iron polysacchar complx/iron heme polypeptide/folic acid/b12
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 calcium lactate calcium lactate REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 calcium amino acid chelate
calcium amino acid chelate REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 coral calcium calcium carb/cholecalciferol/magnesi um amino acid chelate
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 CAL-MAG calcium carbonate/magnesium oxide, carbonate
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 REPLESTA cholecalciferol (vitamin d3) REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 COLYTE WITH FLAVOR PACKS
peg 3350/sod sulf/sod bicarb/sod chloride/potassium chloride
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 halflytely- bisacodyl,peg- prep,gavilyte-h and bisacodyl
bisacodyl/sodium chlor/sodium bicarb/potassium chl/peg 3350
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 SUPREP sodium sulfate/potassium sulfate/magnesium sulfate
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 METAMUCIL,ME TAMUCIL SUGAR FREE
psyllium husk/aspartame REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 169 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/19/2016 complete multivitamin- mineral,multivita min
multivitamin with minerals/ferrous fumarate
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 PREPOPIK sodium picosulfate/magnesium oxide/citric acid
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 easy fiber wheat dextrin/calcium carbonate
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 PROTECT IRON multivitamin with minerals no.24/iron ps complex/folic acid
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 UPCAL D calcium citrate/cholecalciferol (vitamin d3)
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 UPCAL D calcium citrate/cholecalciferol (vitamin d3)
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 IROSPAN iron bisgl,ps cmplx/folic acid/vit b,c no.12/succinic acid
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 calcium + d calcium carbonate/cholecalciferol (vitamin d3)
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 calcium in premium chocolate
calcium carbonate/magnesium oxide/cholecalciferol (vit d3)
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 children's calcium gummies
calcium phosphate tribasic/ergocalciferol (vitamin d2)
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 STRESS B- COMPLEX
vitamin b comp w-c/fa/zinc sulfate/copper oxide/vitamin e
REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 170 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/19/2016 VENOFER iron sucrose complex REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 slow release iron ferrous sulfate REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 ferrlecit,sod ferric gluconate complex,nulecit
sodium ferric gluconate complex in sucrose
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 slow release iron,ferrous sulfate
ferrous sulfate REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 calcium 1000 + d3
calcium carbonate/cholecalciferol (vitamin d3)
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 liquid calcium-vit d
calcium carbonate/cholecalciferol (vitamin d3)
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 CALCET PETITES
calcium carbonate, calcium lactate-cholecalciferol (vit d3)
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 PHOSLYRA calcium acetate REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 IRONUP iron polysaccharide complex REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 oyster shell calcium- magnesium
calcium carbonate/magnesium oxide
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 calcium- magnesium-zinc
calcium/magnesium/zinc REMOVE FROM FORMULARY
Non-Formulary
09/19/2016 THERACAL,PRO STEON
calcium cit/vit d3/vit k/mag ox/strontium cit/sodium borate
REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 171 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/19/2016 THERACAL calcium cit/vit d3/vit k/mag ox/strontium cit/sodium borate
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 BLADDER 2.2 multivitamin with minerals/folic acid/lycopene/boron
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 cal mag zinc- d,cal mag zinc-d3
calcium carbonate/vitamin d3/magnesium oxide/zinc oxide
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 b-complex vitamin b complex and vitamin c/calcium carbonate
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 fiber select gummies,fiber gummies
inulin/chromium picolinate REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 animi-3 with vitamin d,animi- 3,bp vit 3 plus
omega- 3/dha/epa/d3/b12/folic acid/pyridox hcl/phytosterol
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 UDAMIN SP multivitamin-minerals no.9/folic acid/saw palmetto extract,multivitamins with min no.9/folic acid/saw palmetto extract
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 ENEMA sodium phosphate,monobasic/sodiu m phosphate,dibasic
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 calcium + d3,citracal + d,calcium + vitamin d3
calcium carbonate and citrate/cholecalciferol (vit d3)
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 SLOW RELEASE IRON
ferrous sulfate, dried REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 COLOX psyllium husk/laxative combination no.1
REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 172 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/19/2016 fiber therapy,soluble fiber therapy
methylcellulose (with sugar) REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 LOCALNESIUM calcium carbonate and citrate/magnesium citrate, glycinate
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 MAXARON FORTE
iron glycin,sul- fumu/vitc/b12/methyltetrahy drofolate calcium
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 diabetes health support
multivit with calcium,minerals/folic acid/bioflavonoids no.4
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 lactulose lactulose REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 NICOMIDE methyltetrahydrofolate glucosamine/niacinamide/cu pric,zn ox
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 INFUVITE ADULT
mvi, adult no.4 with vit k,multivitamin infusion, adult no.4 with vitamin k
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 CARDIAMIN multivitamin with min/folic acid/d3/omega- 3/dha/epa/fish oil
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 LOCALNESIUM- C
calcium carbonate/magnesium oxide/ascorbic acid
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 GLYCERIN LAXATIVE
glycerin REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 calcium phosphate
calcium phosphate REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 doxercalciferol doxercalciferol REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 173 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/19/2016 senna leaves senna leaf,senna REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 ADVANCED CALCIUM
calcium citrate/minerals/vitamin d3/vit k2/silicon dioxide
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 CAL-QUICK calcium carbonate/cholecalciferol (vitamin d3)
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 ceftazidime,fortaz ,tazicef
ceftazidime pentahydrate,ceftazidime
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 FOSRENOL lanthanum carbonate REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 FOSRENOL lanthanum carbonate REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 psyllium seed psyllium husk REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 DIALYVITE VITAMIN D3 MAX
cholecalciferol (vitamin d3) REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 calcium,citracal + d3
calcium phosphate, tribasic/cholecalciferol (vitamin d3)
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 PARVA-CAL 250 calcium carbonate,calcium gluconate/ergocalciferol (vit d2)
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 ALKA-SELTZER HEARTBURN
sodium bicarbonate/sodium citrate
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 NOVAFERRUM iron polysaccharide complex REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 NOVAFERRUM 125
iron polysaccharide complex/cholecalciferol (vit d3)
REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 174 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/19/2016 NOVAFERRUM 50
iron polysaccharide complex REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 CENTRUM SPECIALIST ENERGY
multivitamin-minerals/iron fumarate/fa/vit k/korean ginseng
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 E-Z-GAS II simethicone/sodium bicarbonate/citric acid
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 DIABETES HEALTH PACK
multivit,calc,mins/vit k/omg- 3/vit d3/mag/c/gr.tea/chromium
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 caltrate 600+d plus,calcium 600- d3-minerals
calcium carbonate/vit d3/mag ox/zinc/copper/manganese/ boron
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 CALTRATE 600+D PLUS
calcium carb/d3/mag 11/zinc/cupric sulf/manganese/s.borate
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 calcium + d,calcium 500 + vit d,citracal,calcium soft chew
calcium carbonate/cholecalciferol (vit d3)/vit k1,calcium carbonate/cholecalciferol (vit d3)/phytonadione
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 acetaminophen- codeine
acetaminophen with codeine phosphate
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 icar,iron chews iron,carbonyl REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 ONE-A-DAY WOMEN'S
multivitamin-minerals/iron fum/folic acid/calcium carb/vit k
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 ferate,iron ferrous gluconate REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 175 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/19/2016 THERANATAL LACTATION SUPPORT
multivit-minerals/iron/folic acid/k/d3/choline/dha/fish oil
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 CALMAG THINS calcium carbonate and citrate/magnesium oxide
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 FUSION PLUS iron fum,polysac comp/folic acid/vit b compc no.18/l. casei
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 child's fiber select gummies,fiber choice
inulin REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 SUCLEAR polyethylene glycol 3350/bowel prep no.2,two part prep
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 IRON 21/7 iron bis-glycinate chelate/fa/vit c/b12/ca- thr/succinic acid
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 VITRON-C iron,carbonyl/ascorbic acid REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 FERIVA iron bisgly,carbonyl/folic acid/vit c/cyanocobalamin/biotin
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 OXI-FREEDA multivit with minerals/glutathione/cystein e
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 fiber-stat,fiberex f15
fructooligosaccharides/polyd extrose
REMOVE FROM FORMULARY
Non-Formulary
09/19/2016 ACTIVE FE iron,carbonyl/folic acid/multivit with minerals
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 calcium adult calcium phosphate, tribasic/cholecalciferol (vitamin d3)
REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 176 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/19/2016 KONSYL psyllium husk REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 DOCUSOL PLUS docusate sodium/benzocaine
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 CORVITE FE iron/methyltetrahydrofolate gluc,folate/multivit,mins no.40
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 FERRETTS iron,carbonyl REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 MACULAR VITAMIN
multivit with minerals/folic acid/lutein/zeaxanthin
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 CORVITE 150 iron,carbonyl/methyltetrahyd rofolate,folic acid/mv,min no.41
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 CALTRATE 600 + D
calcium carbonate/cholecalciferol (vitamin d3)
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 CALCI-MAX calcium/folic ac/b complex/d3/e/citrus bioflavonoids/soybean
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 BENEFIBER wheat dextrin REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 IRO-PLEX iron/vit c/b12/b6/e/folic acid/intrinsic factor/senna leaf
REMOVE FROM FORMULARY
Covered Non-Formulary
09/19/2016 ABATRON AF iron/folic acid/vit c/e/b12/biotin/cupric sulf/docusate sod
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 DOCUSOL KIDS docusate sodium REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 KONSYL psyllium husk/aspartame REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 177 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/20/2016 VELPHORO sucroferric oxyhydroxide REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 KONSYL EASY MIX
psyllium husk REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 KONSYL FORMULA-D
psyllium husk (with dextrose)
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 konsyl,metamucil psyllium husk (with sugar) REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 ABATRON iron/folic acid/vit b complex no.16/mag sulfate/zinc sulfate
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 FLINTSTONES BONE SUPPORT
calcium phosphate, tribasic/cholecalciferol (vitamin d3)
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 calcium 600-vit d,calcium 600-d- minerals,calcium 600-d3 plus
calcium carbonate/vit d3/mag ox/zinc/copper/manganese/ boron
REMOVE FROM FORMULARY
Non-Formulary
09/20/2016 KONSYL psyllium husk REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 calcium citrate plus
calcium cit/magnesium/d3/zinc ox/copper gluc/manganese gluc
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 KONSYL BALANCE
psyllium husk/inulin/aspartame
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 fiber with probiotic
wheat dextrin/lactobacillus acidophilus/aspartame
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 MAXFE iron carb,bg/methylfolate/b12/ma g ascorbate/biotin/zinc/dss
REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 178 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/20/2016 CALTRATE 600- D3 PLUS MINERALS
calcium carb/vit d3/mag ox/zinc/copper/manganese/ mg borate
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 BONE ESSENTIALS
calcium hydroxyapatite/vitamin d3/vitamin c/vit k2/minerals
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 AURYXIA ferric citrate REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 PERFECT IRON iron,carbonyl REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 THERAMILL FORTE
multivit-min/folic acid/inositol/choline bit/bioflav,citrus
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 FERIVA 21-7 iron asp gly/folate no.1/c/b12/zinc/docusate/su ccinic acid
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 paricalcitol paricalcitol REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 paricalcitol paricalcitol REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 calcium-vitamin d3,caltrate gummy bites
calcium phosphate, tribasic/cholecalciferol (vitamin d3)
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 NICOMIDE levomefolate calc/niacinamide/copper/zin c/selenium/chromium
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 FUSION iron fumarate-iron polysaccharide combo no.1/vit c/l. casei
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 FERIVA FA iron bisgly,aspart,fum/folate 1/vit c/b12/biotin/copper/dss
REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 179 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/20/2016 BEROCCA multivit with minerals/folic acid/guarana/caffeine
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 antacid calcium carbonate/magnesium hydroxide
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 ALKA-SELTZER HEARTBURN+G AS
calcium carbonate/simethicone
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 ALKA-SELTZER potassium bicarbonate/sodium bicarbonate/citric acid
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 ONE-A-DAY VITACRAVES ENERGY
multivitamin with minerals/folic acid/caffeine
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 cephalexin cephalexin REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 MEN'S POTENT FORMULA
calcium/vitamin e/folic acid/pyridoxine/herbal drugs
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 rolaids,antacid,ac id relief
calcium carbonate/magnesium hydroxide
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 ZEMPLAR paricalcitol REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 calcium citrate plus,calcium citrate + d
calcium citrate/magnesium oxide/vitamin d3/pyridoxine/min
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 NATURAL VEGETABLE LAXATIVE
senna/fennel REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 calcium- magnesium-zinc
calcium carbonate/magnesium oxide/copper/zinc oxide
REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 180 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/20/2016 hectorol,doxercal ciferol
doxercalciferol REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 METAMUCIL,ME TA FIBER WAFER
psyllium seed (with sugar),psyllium husk (with sugar)
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 antioxidant formula,antioxida nt,one-a-day antioxidant
beta-carotene (vitamin a) with vitamins c and e/minerals,beta-carotene(a) w-c & e/minerals,beta- carotene(a) w-c & e
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 calcium citrate- vitamin d
calcium citrate/ergocalciferol (vitamin d2)
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 calcium- magnesium-zinc
calcium/magnesium/zinc REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 I.L.X. B- 12,SENILEZOL
iron/vitamin b complex/cyanocobalamin/liv er extract,thiamine/riboflavin/ni acin/ca pantothenate/vit b6/b12/iron
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 trigels-f forte,ferrogels forte,hematogen forte
ferrous fumarate/ascorbic acid/cyanocobalamin/folic acid
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 hematogen fa ferrous fumarate/ascorbic acid/cyanocobalamin/folic acid
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 foltrin,ferotrinsic,tl icon,ferocon,trico n,ferotrin,conison
ferrous fumarate/ascorbic acid/b12-if/folic acid
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 tl-fol 500,folitab 500,fero-folic-500
ferrous sulfate/ascorbic acid/folic acid
REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 181 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/20/2016 hemocyte- f,hematinic with folic acid,ferrocite-f
ferrous fumarate/folic acid REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 NEPHRON FA ferrous fumarate/docusate/folic acid/vitamin b comp and c
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 iron with stool softener
ferrous fumarate/docusate sodium
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 ferrocite plus,hematinic plus
iron/folic acid/vitamin b comp and c/minerals,iron/folic acid/vitamin b comp w- c/minerals,ferrous fumarate/folic acid/multivitamins with min no. 15
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 biotect plus,tyr cooler,protect plus
amino acids/multivitamin,therapeuti c,iron,other minerals,amino acids/multivits w-fe,other min
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 mylanta supreme antacid,supreme antacid,antacid supreme
calcium carbonate/magnesium hydroxide
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 GAVISCON magnesium carbonate/aluminum hydroxide/alginic acid
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 mi-acid ds,mylanta,mylan ta ultra
calcium carbonate/magnesium hydroxide
REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 182 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/20/2016 antacid- antigas,antacid ii with simethicone,mas anti double strength
magnesium hydroxide/aluminum hydroxide/simethicone
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 ri-mox plus,alamag plus
magnesium hydroxide/aluminum hydroxide/simethicone
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 mintox plus,alamag- plus,antacid with simethicone,gelu sil,magalox plus,antacid plus,almacone
magnesium hydroxide/aluminum hydroxide/simethicone
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 MAG-AL magnesium hydroxide/aluminum hydroxide
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 gaviscon,heartbu rn antacid,acid gone,antacid extra strength,foaming antacid,heartburn relief
magnesium carbonate/aluminum hydroxide,calcium carbonate
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 ron acid plus,ri mag plus
magaldrate/simethicone REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 KONDREMUL mineral oil/carrageenan REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 183 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/20/2016 phosphate laxative,oral saline laxative,wal- phosphate,saline laxative,phospho- soda
sodium phosphate,monobasic/sodiu m phosphate,dibasic
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 CEO-TWO potassium bitartrate/sodium bicarbonate
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 HEMATRON ferric ammonium citrate/lysine/vitamin b complex/folic acid
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 kelp-lecithin-vit b- 6
lecithin/pyridoxine/kelp REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 NUTRIVIT iron/lysine/vitamin b complex/folic acid
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 kelp-lecithin-b-6- vinegar,kelp- lecithin-vit b-6
lecithin/pyridoxine/kelp REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 KONSYL psyllium husk/aspartame REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 VENOFER iron sucrose complex REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 calcium citrate calcium citrate REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 calcium 600 with soy,calcium 600 plus soy
calcium carbonate/ergocalciferol (vit d2)/soybean
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 calcium + vit d calcium carbonate/cholecalciferol (vitamin d3)
REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 184 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/20/2016 naprelan,naproxe n sodium er,naproxen sodium cr
naproxen sodium REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 high potency iron,ferrous sulfate
ferrous sulfate REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 calcium with boron
calcium carbonate/boron gluconate
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 wee care,icar iron,carbonyl REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 MAGNEBIND 400 RX
calcium carbonate/magnesium carbonate/folic acid
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 vitamin b- complex & c,stress b-100 with vitamin c
b-complex with vitamin c,b complex with vitamin c
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 vitamin b- complex with vit c,support- 500,super b with vit c,super b complex with c
b-complex with vitamin c REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 vitamin a and d vitamins a and d REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 icar-c,iron 100- vitamin c,fe c
iron,carbonyl/ascorbic acid REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 multivitamins multivitamin REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 185 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/20/2016 vimar,multi- delyn,my favorite multiple,super nu- thera,vitamin,dail y vitamin,thera vite
multivitamin REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 kenwood therapeutic,thera- plus,theravite,the
multivitamin,therapeutic,mult ivitamins,therapeutic
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 totalday multiple multivitamin with minerals REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 therapeutic vitamin & mineral,theramill forte,multivitamin s with minerals hp
multivitamins,ther w- minerals,multivitamin,therap eutic with minerals
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 apatate forte,support,bios upp
multivitamin with minerals REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 clusimar,biovol multivitamin with minerals REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 stress formula with iron,stress with iron,stress b with iron
iron/multivitamin,stress formula,iron/multivits,stress formula
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 superior 35 multivitamin with iron and other minerals
REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 186 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/20/2016 central- vite,centravites,s pectravite,centra- vite,century,centa min
multivitamin with iron,hematinic,multivits w- iron,hematinic,multivitamin with minerals
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 SUPER CAL- MAG
calcium carbonate/magnesium oxide
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 niferex-150,ferrex 150 plus,fe-tinic 150,rexavite 150
iron polysaccharides complex,iron asp gly,ps cmplx/ascorb calcium/ca- thr/succinic acid,iron asp gly& ps cmplx/ascorb calcium/ca-thr/succinic acid,ferrous bis-glycinate chelate/fe ps cmplx/vit c/ca- threonate
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 ferroflex 150 forte,ferrex 150 forte plus,niferex- 150 forte,triferex 150 forte,fe-tinic 150 forte,rexavite 150 forte,iron ag- ps-asc-b12-fa- thre-suc
iron asp gly&ps cmplx/ascorb.cal/vit b12/fa/ca-thr/succ.acid,iron asp,gly,ps/ascorb.calcium/b 12/folic/calcium/succ.acid
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 ferrovite fa,multigen folic,chromagen fa,trimagen fa
iron asp gly/ascorb.cal/vit b12/fa/ca-threonte/succinic acid
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 ferrovite,multigen ,chromagen,trima gen,anemagen,vi tagen advance,mv-iron- asc-b12-thre-suc- stom
iron aspgly/ascorb.cal/vit b12/calcium thr/succ.acid/stomach,iron/vi t c/vit b12/calcium threon/succinic acid/stomach conc
REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 187 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/20/2016 ferrovite forte,multigen plus,chromagen forte,trimagen forte,anemagen forte,vitagen forte,mv-iron fum- asp-asc-b12-fa- suc
iron fumarte &asp gly/ascorb.cal/vit b12/fa/ca- thr/succ.acid,iron fum,ag/ascorb.calcium/b12/f olic acid/calcium/succ.acid
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 MOVIPREP peg 3350/sodium sulfate/sod chloride/kcl/ascorbate sod/vit c
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 MULTICHEW multivit, iron, minerals no. 4/ferrous fumarate/folic acid
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 oral saline laxative,phosphat e laxative,preparati on cleansing,oral saline laxative kit,fleet phospho- soda
sodium phosphate,monobasic/sodiu m phosphate,dibasic
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 milk of magnesia magnesium hydroxide REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 calcium 600+minerals,cal cium 600+d plus minerals,calcium- vitamin d,calcium 600+d & minerals,calcium plus,calcium 600- d3- minerals,caltrate- 600 plus
calcium carbonate/cholecalciferol (vit d3)/minerals
REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 188 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/20/2016 calcium- magnesium-zinc- vit d
calcium carbonate/vit d3/magnesium oxide,stearate/zinc sulf
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 sodium bicarbonate
sodium bicarbonate REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 calcium plus vitamin d
calcium carbonate/vit d3/mag ox/zinc/copper/manganese/ boron
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 citrucel,fiber therapy
methylcellulose (with sugar) REMOVE FROM FORMULARY
Non-Formulary
09/20/2016 viactiv,calcium soft chew,calcium + vitamin d & k
calcium carbonate/cholecalciferol (vit d3)/phytonadione,calcium carbonate/cholecalciferol (vit d3)/vit k1
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 GOLYTELY peg 3350/sod sulf/sod bicarb/sod chloride/potassium chloride
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 castor oil castor oil REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 calcium 600+d & minerals,calcium 600-vit d3- mineral,calcium +d & minerals
calcium carbonate/cholecalciferol (vit d3)/minerals,calcium carbonate/vit d3/mag ox/zinc/copper/manganese/ boron
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 calcium calcium carbonate/cholecalciferol (vit d3)/minerals
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 calcium 600+minerals
calcium carbonate/cholecalciferol (vit d3)/minerals
REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 189 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/20/2016 HEMATOGEN ferrous fumarate/ascorbic acid/cyanocobalamin/stoma ch conc
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 ELDERCAPS multivitamin with minerals no.5/folic acid
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 ferrex 28,repliva 21-7,pruvate 21- 7,se-vate 21-7
iron asp.gly,fum/vit c/folic acid/m-vit no.11/calcium threon,iron asp.glycin & fumarate /vit c/fa/mv comb 11/ca-threonate
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 MYKIDZ IRON 10
ferrous sulfate REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 corvita 150,corvite 150
iron,carbonyl/folic acid/vit c/pyridoxine hcl/vit b12/zinc
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 vitamins for hair multivit with iron,mins/folic acid/inositol/choline bit/paba
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 calcium 600 + vit d,calcium creamies
calcium carbonate/cholecalciferol (vitamin d3)
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 PRO FE iron polysaccharide complex REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 calcium magnesium + d
calcium carbonate/magnesium oxide/cholecalciferol (vit d3)
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 vit 3,animi-3,mi- omega nf
omega-3/dha/epa/b12/folic acid/pyridoxine hcl/phytosterols
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 maxaron forte,taron forte
iron bisgly & ps cmplx/ascorbate ca/b12/folic acid/ca-threo,iron bisgly,pscmplx/ascorbate calc/b12/folic acid/calc-threo
REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 190 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/20/2016 hydrocodone- acetaminophen
hydrocodone bitartrate/acetaminophen
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 FERRETTS ferrous fumarate REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 CORAL CALCIUM
calcium/magnesium oxide/cholecalciferol (vitamin d3)
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 BIO-35 multivit,calcium,iron,mineral s/folic acid/lutein/herbal 153
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 ferraplus 90,iron iron, carbonyl/folic acid/vit b12/vitamin c/docusate sodium,iron,carbonyl/folic acid/vitamin b12/vitamin c/docusate na
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 coral calcium calcium carbonate REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 calcium gluconate
calcium gluconate REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 calcium 500,healthy bone formula
calcium carbonate,citrate/magnesiu m oxide,aspartate/vit d3,calcium carbonate & citrate/mag comb no.12/cholecalciferol
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 lescol,fluvastatin sodium
fluvastatin sodium CHANGE UM: QUANTITY 2 / days
09/20/2016 NICOTROL nicotine ADD UM: QUANTITY 168 / 30 days 09/20/2016 obstetrix
dha,obtrex dha prenatal vits no.12/iron,carb/folic acid/docusate/omega-3
ADD UM: QUANTITY 2 / days
09/20/2016 budesonide,pulmi cort
budesonide CHANGE UM: QUANTITY 4 / days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 191 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/20/2016 budesonide,pulmi cort
budesonide CHANGE UM: QUANTITY 4 / days
09/20/2016 citranatal b- calm,taron-bc
prenatal vit with calcium comb no.63/iron,carbonyl/fa/b6,pre natal vit with calcium 63/iron,carb/folic acid/pyridoxine
ADD UM: QUANTITY 1 / days
09/20/2016 vol- nate,trinate,virt nate,virt-nate
multivitamin with minerals no.64/ferrous fumarate/folic acid,prenatal vits with calcium no.73/ferrous fumarate/folic acid
ADD UM: QUANTITY 1 / days
09/20/2016 co-natal fa,venatal- fa,prenatabs fa,pretab
prenatal vitamins comb no.78/ferrous fumarate/folic acid,prenatal vits with calcium no.78/ferrous fumarate/folic acid
ADD UM: QUANTITY 1 / days
09/20/2016 nestabs dha,nutri-tab ob + dha,v-natal dha,tri-tabs dha
prenatal vits with calcium no.87/iron bisgly/folic acid/dha,prenatal vitamins comb no.87/iron bisgly/folic acid/dha
ADD UM: QUANTITY 2 / days
09/20/2016 CREON lipase/protease/amylase ADD UM: QUANTITY 336 / days 09/20/2016 CREON lipase/protease/amylase ADD UM: QUANTITY 28 / days 09/20/2016 PRENATE AM prenatal vit
114/methyltetrahydfolate gluc,folic acid/ginger
ADD UM: QUANTITY 1 / days
09/20/2016 prenatal 19 prenatal vits with calcium no.115/iron fumarate/folic acid
ADD UM: QUANTITY 1 / days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 192 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/20/2016 children's motrin,children's ibuprofen,ibuprof en,children's advil,child ibuprofen,childre n's profen ib,children's profenib,children' s medi- profen,motrin
ibuprofen CHANGE UM: QUANTITY 480 / 30 days
09/20/2016 mynatal,inatal gt prenatal vitamins with calcium/iron,carb/docusate/f olic acid,prenatal vitamins with calcium/iron,carbonyl/docus ate/fa
ADD UM: QUANTITY 1 / days
09/20/2016 pramipexole dihydrochloride,m irapex
pramipexole di-hcl CHANGE UM: QUANTITY 3 / days
09/20/2016 men's biomultiple multivit with minerals/herbal drugs
REMOVE FROM FORMULARY
Covered Non-Formulary
09/20/2016 STIMATE desmopressin acetate ADD UM: AUTHORIZATION PA applies 09/20/2016 ddavp,desmopre
ssin acetate desmopressin acetate ADD UM: AUTHORIZATION PA applies
09/20/2016 tizanidine hcl,zanaflex
tizanidine hcl REMOVE UM: AGE Up to 64 yrs old
09/20/2016 tizanidine hcl,zanaflex
tizanidine hcl REMOVE UM: AGE Up to 64 yrs old
09/27/2016 testosterone cypionate
testosterone cypionate CHANGE TIER Covered
09/27/2016 testosterone cypionate
testosterone cypionate CHANGE UM: GENDER Male
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 193 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/28/2016 bupropion hcl sr,bupropion hcl er
bupropion hcl CHANGE TIER Covered
09/28/2016 bupropion hcl sr,bupropion hcl er
bupropion hcl CHANGE UM: QUANTITY 2 / days
09/28/2016 budeprion sr,wellbutrin sr,bupropion hcl sr
bupropion hcl REMOVE FROM FORMULARY
Non-Formulary
09/28/2016 budeprion sr,wellbutrin sr,bupropion hcl sr
bupropion hcl CHANGE UM: CUSTOM CARVE OUT DRUG-Bill
MDCH FFS
09/28/2016 budeprion sr,wellbutrin sr,bupropion hcl sr
bupropion hcl REMOVE UM: QUANTITY
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 194 UPDATED 10/2018
October, 2016
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/17/2016 acetaminophen-
codeine acetaminophen with codeine phosphate
REMOVE FROM FORMULARY
Covered Non-Formulary
10/20/2016 omeprazole,prilos ec
omeprazole CHANGE UM: QUANTITY 2 / days
10/24/2016 ORKAMBI lumacaftor/ivacaftor ADD UM: CUSTOM Carveout Drug- Bill MDCH FFS
10/27/2016 kytril,granisetron hcl
granisetron hcl CHANGE UM: QUANTITY 4 / 30 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 195 UPDATED 10/2018
November, 2016
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/21/2016 enema,enema
disposable,phosp hate enema,saline enema,disposabl e enema,fleet enema,complete ready-to-use enema,curad enema,pure & gentle saline enema
sodium phosphate,monobasic/sodiu m phosphate,dibasic
ADD UM: CUSTOM Covered For CSHCS Only
11/21/2016 b complex with vitamin c
thiamine m.nit/riboflavin/niacin/ca pantothenate/b6/b12/c/fa
ADD UM: CUSTOM Covered For CSHCS Only
11/21/2016 vitamin e vitamin e ADD UM: CUSTOM Covered for CSHCS Only
11/21/2016 MAGONATE magnesium carbonate ADD UM: CUSTOM Covered For CSHCS Only
11/21/2016 NEPHROCAPS QT
vitamin b complex with vitamin c no.13/folic acid/vitamin d3,vitamin b complex & vitamin c no.13/folic acid/vitamin d3
ADD UM: CUSTOM Covered For CSHCS Only
11/21/2016 folic acid-vit b6- vit b12,folplex 2.2,folcaps,comb gen,foleve
cyanocobalamin/folic acid/pyridoxine
ADD UM: CUSTOM Covered for CSHCS Only
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 196 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
11/21/2016 folgard rx,allanfol rx,tl gard rx,foleve plus,fabb,virt- gard
cyanocobalamin/folic acid/pyridoxine
ADD UM: CUSTOM Covered For CSHCS Only
11/21/2016 FOLGARD cholecalciferol/folic acid/riboflavin/pyridoxine hcl/vit b12
ADD UM: CUSTOM Covered For CSHCS Only
11/21/2016 mineral oil enema,mineral oil,ready to use enema,enema,fle et mineral oil enema
mineral oil ADD UM: CUSTOM Covered For CSHCS Only
11/21/2016 senna- gen,senna,senex on,senna lax,senna laxative,natural senna laxative,sen-o- tab,senokot,veget able laxative,medi- natural,sennoside s,senna-c,senna concentrate,senn o,senokot to go,natural laxative,geri- kot,sennagen,sen nacon,laxative,na tural vegetable laxative,evac-u- gen
sennosides ADD UM: CUSTOM Covered For CSHCS Only
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 197 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
11/21/2016 ex- lax,perdiem,senn a soft,laxative pills,laxative,medi -lax
sennosides ADD UM: CUSTOM Covered For CSHCS Only
11/21/2016 ex-lax maximum strength,laxative pills,laxative maximum strength,senna laxative,laxative,n atural laxative,laxative- senna
sennosides ADD UM: CUSTOM Covered For CSHCS Only
11/21/2016 meribin,biotin biotin ADD UM: CUSTOM Covered For CSHCS Only
11/21/2016 hard nails,biotin biotin ADD UM: CUSTOM Covered For CSHCS Only
11/21/2016 magnesium sulfate
magnesium sulfate ADD UM: CUSTOM Covered For CSHCS Only
11/21/2016 magnesium sulfate
magnesium sulfate ADD UM: CUSTOM Covered For CSHCS Only
11/21/2016 magnesium sulfate-d5w
magnesium sulfate/dextrose 5 % in water
CHANGE TIER Covered
11/21/2016 magnesium sulfate-d5w
magnesium sulfate/dextrose 5 % in water
ADD UM: CUSTOM Covered For CSHCS Only
11/21/2016 magnesium sulfate
magnesium sulfate in sterile water
ADD UM: CUSTOM Covered For CSHCS Only
11/21/2016 magnesium sulfate
magnesium sulfate in sterile water
CHANGE TIER Covered
11/21/2016 magnesium sulfate
magnesium sulfate in sterile water
CHANGE TIER Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 198 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
11/21/2016 magnesium sulfate
magnesium sulfate in sterile water
ADD UM: CUSTOM Covered For CSHCS Only
11/21/2016 magnesium sulfate
magnesium sulfate in sterile water
CHANGE TIER Covered
11/21/2016 magnesium sulfate
magnesium sulfate in sterile water
ADD UM: CUSTOM Covered For CSHCS Only
11/21/2016 magnesium sulfate
magnesium sulfate in sterile water
CHANGE TIER Covered
11/21/2016 magnesium sulfate
magnesium sulfate in sterile water
ADD UM: CUSTOM Covered For CSHCS Only
11/21/2016 magnesium sulfate
magnesium sulfate in sterile water
CHANGE TIER Covered
11/21/2016 magnesium sulfate
magnesium sulfate in sterile water
ADD UM: CUSTOM Covered For CSHCS Only
11/21/2016 sodium phosphate
sodium phosphate,monobasic- dibasic
ADD UM: CUSTOM Covered For CSHCS Only
11/21/2016 ECEE PLUS vitamin e acid succ/ascorbic acid/magnesium sulf/zinc sulfat
ADD UM: CUSTOM Covered For CSHCS Only
11/21/2016 BEELITH magnesium oxide/pyridoxine hcl (b6)
ADD UM: CUSTOM Covered For CSHCS Only
11/21/2016 potaba,aminoben zoate potassium
potassium aminobenzoate ADD UM: CUSTOM Covered For CSHCS Only
11/21/2016 hydralazine hcl hydralazine hcl ADD UM: CUSTOM Covered For CSHCS Only
11/21/2016 potassium phosphate
potassium phosphate,monobasic- dibasic,potassium phos,m- basic-d-basic
ADD UM: CUSTOM Covered For CSHCS Only
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 199 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
11/21/2016 magnesium chloride
magnesium chloride ADD UM: CUSTOM Covered For CSHCS Only
11/21/2016 cerefolin,rovin-cf of,enfolast,metaf olbic,l-methyl-
cyanocobalamin/levomefolat e calcium/pyridoxine/riboflavin
ADD UM: CUSTOM Covered For CSHCS Only
11/21/2016 foltx,lmthf- pyridoxine- cyanocobal,folbic rf,cyanocobal- levomef- pyridoxine
cyanocobalamin/levomefolat e calcium/pyridoxine hcl (b6)
ADD UM: CUSTOM Covered For CSHCS Only
11/21/2016 enema,enema disposable,phosp hate enema,saline enema,disposabl e enema,fleet enema,complete ready-to-use enema,curad enema,pure & gentle saline enema
sodium phosphate,monobasic/sodiu m phosphate,dibasic
REMOVE UM: CUSTOM Covered For CSHCS Only
11/21/2016 b complex with vitamin c
thiamine m.nit/riboflavin/niacin/ca pantothenate/b6/b12/c/fa
REMOVE UM: CUSTOM Covered For CSHCS Only
11/21/2016 vitamin e vitamin e REMOVE UM: CUSTOM Covered for CSHCS Only
11/21/2016 MAGONATE magnesium carbonate REMOVE UM: CUSTOM Covered For CSHCS Only
11/21/2016 NEPHROCAPS QT
vitamin b complex with vitamin c no.13/folic acid/vitamin d3,vitamin b complex & vitamin c no.13/folic acid/vitamin d3
REMOVE UM: CUSTOM Covered For CSHCS Only
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 200 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
11/21/2016 folic acid-vit b6- vit b12,folplex 2.2,folcaps,comb gen,foleve
cyanocobalamin/folic acid/pyridoxine
REMOVE UM: CUSTOM Covered for CSHCS Only
11/21/2016 folgard rx,allanfol rx,tl gard rx,foleve plus,fabb,virt- gard
cyanocobalamin/folic acid/pyridoxine
REMOVE UM: CUSTOM Covered For CSHCS Only
11/21/2016 FOLGARD cholecalciferol/folic acid/riboflavin/pyridoxine hcl/vit b12
REMOVE UM: CUSTOM Covered For CSHCS Only
11/21/2016 mineral oil enema,mineral oil,ready to use enema,enema,fle et mineral oil enema
mineral oil REMOVE UM: CUSTOM Covered For CSHCS Only
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 201 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
11/21/2016 senna- gen,senna,senex on,senna lax,senna laxative,natural senna laxative,sen-o- tab,senokot,veget able laxative,medi- natural,sennoside s,senna-c,senna concentrate,senn o,senokot to go,natural laxative,geri- kot,sennagen,sen nacon,laxative,na tural vegetable laxative,evac-u- gen
sennosides REMOVE UM: CUSTOM Covered For CSHCS Only
11/21/2016 ex- lax,perdiem,senn a soft,laxative pills,laxative,medi -lax
sennosides REMOVE UM: CUSTOM Covered For CSHCS Only
11/21/2016 ex-lax maximum strength,laxative pills,laxative maximum strength,senna laxative,laxative,n atural laxative,laxative- senna
sennosides REMOVE UM: CUSTOM Covered For CSHCS Only
11/21/2016 meribin,biotin biotin REMOVE UM: CUSTOM Covered For CSHCS Only
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 202 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
11/21/2016 hard nails,biotin biotin REMOVE UM: CUSTOM Covered For CSHCS Only
11/21/2016 magnesium sulfate
magnesium sulfate REMOVE UM: CUSTOM Covered For CSHCS Only
11/21/2016 magnesium sulfate
magnesium sulfate REMOVE UM: CUSTOM Covered For CSHCS Only
11/21/2016 magnesium sulfate-d5w
magnesium sulfate/dextrose 5 % in water
REMOVE UM: CUSTOM Covered For CSHCS Only
11/21/2016 magnesium sulfate
magnesium sulfate in sterile water
REMOVE UM: CUSTOM Covered For CSHCS Only
11/21/2016 magnesium sulfate
magnesium sulfate in sterile water
REMOVE UM: CUSTOM Covered For CSHCS Only
11/21/2016 magnesium sulfate
magnesium sulfate in sterile water
REMOVE UM: CUSTOM Covered For CSHCS Only
11/21/2016 magnesium sulfate
magnesium sulfate in sterile water
REMOVE UM: CUSTOM Covered For CSHCS Only
11/21/2016 magnesium sulfate
magnesium sulfate in sterile water
REMOVE UM: CUSTOM Covered For CSHCS Only
11/21/2016 sodium phosphate
sodium phosphate,monobasic- dibasic
REMOVE UM: CUSTOM Covered For CSHCS Only
11/21/2016 ECEE PLUS vitamin e acid succ/ascorbic acid/magnesium sulf/zinc sulfat
REMOVE UM: CUSTOM Covered For CSHCS Only
11/21/2016 BEELITH magnesium oxide/pyridoxine hcl (b6)
REMOVE UM: CUSTOM Covered For CSHCS Only
11/21/2016 potaba,aminoben zoate potassium
potassium aminobenzoate REMOVE UM: CUSTOM Covered For CSHCS Only
11/21/2016 hydralazine hcl hydralazine hcl REMOVE UM: CUSTOM Covered For CSHCS Only
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 203 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
11/21/2016 potassium phosphate
potassium phosphate,monobasic- dibasic,potassium phos,m- basic-d-basic
REMOVE UM: CUSTOM Covered For CSHCS Only
11/21/2016 magnesium chloride
magnesium chloride REMOVE UM: CUSTOM Covered For CSHCS Only
11/21/2016 cerefolin,rovin-cf of,enfolast,metaf olbic,l-methyl-
cyanocobalamin/levomefolat e calcium/pyridoxine/riboflavin
REMOVE UM: CUSTOM Covered For CSHCS Only
11/21/2016 foltx,lmthf- pyridoxine- cyanocobal,folbic rf,cyanocobal- levomef- pyridoxine
cyanocobalamin/levomefolat e calcium/pyridoxine hcl (b6)
REMOVE UM: CUSTOM Covered For CSHCS Only
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 204 UPDATED 10/2018
December, 2016
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 12/01/2016 GRANIX tbo-filgrastim ADD TO FORMULARY Covered 12/01/2016 GRANIX tbo-filgrastim ADD TO FORMULARY Covered 12/01/2016 sodium fluoride fluoride (sodium),sodium
fluoride CHANGE UM: QUANTITY 2 / Day 4 / 1 days
12/01/2016 lidocaine hcl lidocaine hcl ADD TO FORMULARY Covered 12/01/2016 ALAWAY ketotifen fumarate CHANGE UM: QUANTITY 0.167 / day 0.3 / 1 days 12/01/2016 eye itch relief ketotifen fumarate CHANGE TIER Covered 12/01/2016 eye itch relief ketotifen fumarate CHANGE UM: QUANTITY 10 / 30 days 12/01/2016 wal-zyr ketotifen fumarate CHANGE UM: QUANTITY 0.167 / day 10 / 30 days 12/01/2016 refresh,zaditor,ke
totifen fumarate,eye itch relief,wal- zyr,zyrtec itchy eye,itchy eye,children's alaway,alaway,all ergy eye,allergy eye drops,antihistami ne eye drops
ketotifen fumarate CHANGE UM: QUANTITY 10 / 30 days
12/01/2016 ciloxan,ciprofloxa cin hcl
ciprofloxacin hcl CHANGE UM: QUANTITY 0.167 / day 2 / 1 days
12/01/2016 FML FORTE fluorometholone CHANGE UM: QUANTITY 10 / 30 Days 10 / 30 days 12/01/2016 acular,ketorolac
tromethamine ketorolac tromethamine CHANGE UM: QUANTITY 0.167 / day .4 / 1 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 205 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
12/01/2016 imdur,isosorbide mononitrate er,isosorbide mononitrate
isosorbide mononitrate CHANGE UM: QUANTITY 2 / 1 days
12/01/2016 calcipotriene,calci trene
calcipotriene CHANGE UM: QUANTITY 2 / Day 4 / 1 days
12/01/2016 diltiazem 24hr er,cardizem cd,diltiazem 24hr cd,cartia xt,dilt- cd,diltiazem er
diltiazem hcl CHANGE UM: QUANTITY 2 / 1 days
12/01/2016 HUMALOG MIX 75-25,HUMALOG MIX 75-25 KWIKPEN
insulin lispro protamine & insulin lispro,insulin lispro protamine and insulin lispro
CHANGE UM: QUANTITY 0.667 / day 30 / 30 days
12/01/2016 HUMALOG MIX 50-50,HUMALOG MIX 50-50 KWIKPEN
insulin lispro protamine & insulin lispro,insulin lispro protamine and insulin lispro
CHANGE UM: QUANTITY .667 / 1 days 30 / 30 days
12/01/2016 HUMALOG insulin lispro CHANGE UM: QUANTITY 0.667 / day 30 / 30 days 12/01/2016 HUMALOG,HUM
ALOG KWIKPEN U-100
insulin lispro CHANGE UM: QUANTITY 0.667 / day 30 / 30 days
12/01/2016 HUMALOG MIX 75-25
insulin lispro protamine and insulin lispro
ADD UM: QUANTITY 60 / 30 days
12/01/2016 HUMALOG MIX 50-50
insulin lispro protamine and insulin lispro
ADD UM: QUANTITY 60 / 30 days
12/01/2016 HUMALOG insulin lispro ADD UM: QUANTITY 60 / 30 days 12/01/2016 allopurinol,zylopri
m allopurinol CHANGE UM: QUANTITY 30 / 30 days
12/01/2016 allopurinol allopurinol CHANGE TIER Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 206 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
12/01/2016 NOVOLOG MIX 70-30 FLEXPEN,NOVO LOG MIX 70-30
insulin aspart protamine human/insulin aspart
CHANGE UM: QUANTITY 0.667 / day 30 / 30 days
12/01/2016 NOVOLOG insulin aspart CHANGE UM: QUANTITY 0.667 / days 30 / 30 days 12/01/2016 NOVOLOG
FLEXPEN insulin aspart CHANGE UM: QUANTITY 0.667 / day 30 / 30 days
12/01/2016 NOVOLOG MIX 70-30
insulin aspart protamine human/insulin aspart
ADD UM: QUANTITY 60 / 30 days
12/01/2016 NOVOLOG insulin aspart ADD UM: QUANTITY 60 / 30 days 12/01/2016 amantadine amantadine hcl CHANGE UM: QUANTITY 20 / Day 40 / 1 days 12/01/2016 DURLAZA aspirin REMOVE FROM
FORMULARY Non-Formulary
12/01/2016 bethanechol chloride,urecholin e
bethanechol chloride CHANGE UM: QUANTITY 2 / Day 4 / 1 days
12/01/2016 bethanechol chloride,urecholin e
bethanechol chloride CHANGE UM: QUANTITY 2 / Day 4 / 1 days
12/01/2016 bethanechol chloride,urecholin e
bethanechol chloride CHANGE UM: QUANTITY 2 / Day 4 / 1 days
12/01/2016 bethanechol chloride,urecholin e
bethanechol chloride CHANGE UM: QUANTITY 2 / Day 4 / 1 days
12/01/2016 HUMULIN 70- 30,NOVOLIN 70- 30 INNOLET,HUMU LIN 70/30 KWIKPEN
insulin nph human isophane/insulin regular, human,nph, human insulin isophane/insulin regular, human
CHANGE UM: QUANTITY 0.667 / Day 30 / 30 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 207 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
12/01/2016 HUMULIN N,NOVOLIN N INNOLET,HUMU LIN N KWIKPEN
insulin nph human isophane,nph, human insulin isophane
CHANGE UM: QUANTITY 0.667 / Day 30 / 30 days
12/01/2016 benzoyl peroxide,benzac ac,persa- gel,bp,acne treatment,benzac w wash,acneclear,p anoxyl,acne 10,desquam- x,acne medication,acne pimple medication
benzoyl peroxide CHANGE UM: QUANTITY 2 / Day 3.78 / 1 days
12/01/2016 APIDRA,APIDRA SOLOSTAR
insulin glulisine CHANGE UM: QUANTITY 2 / days 30 / 30 days
12/01/2016 cleocin,clindamyc in phosphate,clinda max
clindamycin phosphate ADD UM: QUANTITY 40 / fill
12/01/2016 betamethasone dipropionate,dipr osone
betamethasone dipropionate CHANGE UM: QUANTITY 1.5 / day 60 / 30 days
12/01/2016 betamethasone valerate
betamethasone valerate CHANGE UM: QUANTITY 60 / 30 days
12/01/2016 betamethasone valerate
betamethasone valerate CHANGE TIER Covered
12/01/2016 triamcinolone acetonide
triamcinolone acetonide CHANGE UM: QUANTITY 2 / Day 480 / 30 days
12/01/2016 triamcinolone acetonide
triamcinolone acetonide CHANGE UM: QUANTITY 5.333 / day 480 / 30 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 208 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
12/01/2016 triamcinolone acetonide,triderm
triamcinolone acetonide CHANGE UM: QUANTITY 5.333 / day 480 / 30 days
12/01/2016 triamcinolone acetonide
triamcinolone acetonide CHANGE TIER Covered
12/01/2016 triamcinolone acetonide
triamcinolone acetonide CHANGE UM: QUANTITY 480 / 30 days
12/01/2016 triamcinolone acetonide
triamcinolone acetonide CHANGE UM: QUANTITY 5.333 / day 480 / 30 days
12/01/2016 triamcinolone acetonide
triamcinolone acetonide CHANGE TIER Covered
12/01/2016 triamcinolone acetonide
triamcinolone acetonide CHANGE UM: QUANTITY 480 / 30 days
12/01/2016 clobetasol propionate,temov ate,cormax
clobetasol propionate CHANGE UM: QUANTITY 60 / 30 days
12/01/2016 clobetasol propionate,temov ate,embeline,cor max
clobetasol propionate CHANGE UM: QUANTITY 1 / Day 60 / 30 days
12/01/2016 clobetasol propionate,temov ate,embeline,cor max
clobetasol propionate REMOVE UM: AUTHORIZATION
PA applies
12/01/2016 alogliptin alogliptin benzoate ADD TO FORMULARY Covered 12/01/2016 alogliptin alogliptin benzoate ADD TO FORMULARY Covered 12/01/2016 alogliptin alogliptin benzoate ADD TO FORMULARY Covered 12/01/2016 alogliptin-
metformin alogliptin benzoate/metformin hcl
ADD TO FORMULARY Covered
12/01/2016 alogliptin- metformin
alogliptin benzoate/metformin hcl
ADD TO FORMULARY Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 209 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
12/01/2016 alogliptin- pioglitazone
alogliptin benzoate/pioglitazone hcl
ADD TO FORMULARY Covered
12/01/2016 alogliptin- pioglitazone
alogliptin benzoate/pioglitazone hcl
ADD TO FORMULARY Covered
12/01/2016 alogliptin- pioglitazone
alogliptin benzoate/pioglitazone hcl
ADD TO FORMULARY Covered
12/01/2016 alogliptin- pioglitazone
alogliptin benzoate/pioglitazone hcl
ADD TO FORMULARY Covered
12/01/2016 alogliptin- pioglitazone
alogliptin benzoate/pioglitazone hcl
ADD TO FORMULARY Covered
12/01/2016 alogliptin- pioglitazone
alogliptin benzoate/pioglitazone hcl
ADD TO FORMULARY Covered
12/01/2016 TRESIBA FLEXTOUCH U- 200,TRESIBA FLEXTOUCH U- 100
insulin degludec REMOVE FROM FORMULARY
Non-Formulary
12/01/2016 PRESTALIA perindopril arginine/amlodipine besylate
REMOVE FROM FORMULARY
Non-Formulary
12/01/2016 REPATHA SYRINGE,REPA THA SURECLICK,RE PATHA PUSHTRONEX
evolocumab REMOVE FROM FORMULARY
Non-Formulary
12/01/2016 SYNJARDY empagliflozin/metformin hcl REMOVE FROM FORMULARY
Non-Formulary
12/01/2016 PRALUENT PEN,PRALUENT SYRINGE
alirocumab REMOVE FROM FORMULARY
Non-Formulary
12/01/2016 VIBERZI eluxadoline REMOVE FROM FORMULARY
Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 210 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
12/01/2016 VARUBI rolapitant hcl REMOVE FROM FORMULARY
Non-Formulary
12/01/2016 STRENSIQ asfotase alfa REMOVE FROM FORMULARY
Non-Formulary
12/01/2016 buprenorphine hcl,buprenex,sub utex,belbuca,pro buphine
buprenorphine hcl REMOVE FROM FORMULARY
Non-Formulary
12/01/2016 SEEBRI NEOHALER
glycopyrrolate REMOVE FROM FORMULARY
Non-Formulary
12/01/2016 VELTASSA patiromer calcium sorbitex REMOVE FROM FORMULARY
Non-Formulary
12/01/2016 VIVLODEX meloxicam, submicronized REMOVE FROM FORMULARY
Non-Formulary
12/01/2016 UPTRAVI selexipag REMOVE FROM FORMULARY
Non-Formulary
12/01/2016 ticanase,ticaspra y
fluticasone propionate/sodium chloride/sodium bicarbonate
REMOVE FROM FORMULARY
Non-Formulary
12/01/2016 ZARXIO filgrastim-sndz ADD TO FORMULARY Covered 12/01/2016 SPIRIVA
RESPIMAT tiotropium bromide ADD TO FORMULARY Covered
12/01/2016 SPIRIVA RESPIMAT
tiotropium bromide ADD UM: QUANTITY 4 / 30 days
12/01/2016 ENTRESTO sacubitril/valsartan ADD TO FORMULARY Covered 12/01/2016 NARCAN naloxone hcl ADD UM: QUANTITY 2 / 90 days 12/01/2016 clindacin etz clindamycin phosphate ADD TO FORMULARY Covered 12/01/2016 clindamycin
phosphate clindamycin phosphate ADD TO FORMULARY Covered
12/01/2016 clindacin p clindamycin phosphate ADD TO FORMULARY Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 211 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
12/01/2016 elocon,mometaso ne furoate
mometasone furoate CHANGE UM: QUANTITY 1.5 / day 1.67 / 1 days
12/01/2016 diphenhydramine hcl,antihist,valu- dryl,children's allergy,diphedryl, allergy,allergy elixir
diphenhydramine hcl REMOVE UM: AGE Up to 12 yrs old
12/01/2016 metronidazole metronidazole ADD UM: QUANTITY 70 / 1 fill 12/01/2016 omeprazole,prilo
s ec omeprazole CHANGE UM: QUANTITY 30 / 30 days
12/01/2016 LANTUS SOLOSTAR
insulin glargine,human recombinant analog,insulin glargine, human recombinant analog
CHANGE UM: QUANTITY 0.667 / day 30 / 30 days
12/01/2016 nesina,alogliptin alogliptin benzoate CHANGE TIER Covered 12/01/2016 kazano,alogliptin-
metformin alogliptin benzoate/metformin hcl
CHANGE TIER Covered
12/01/2016 oseni,alogliptin- pioglitazone
alogliptin benzoate/pioglitazone hcl
CHANGE TIER Covered
12/15/2016 femcap cervical cap ADD TO FORMULARY Covered 12/15/2016 femcap cervical cap ADD TO FORMULARY Covered 12/15/2016 femcap cervical cap ADD TO FORMULARY Covered 12/28/2016 oseltamivir
phosphate oseltamivir phosphate ADD TO FORMULARY Covered
12/28/2016 oseltamivir phosphate
oseltamivir phosphate ADD UM: QUANTITY 10 / 1 rx
12/28/2016 oseltamivir phosphate
oseltamivir phosphate ADD UM: CUSTOM Max 20 per 180 days
12/28/2016 TAMIFLU oseltamivir phosphate REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 212 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
12/28/2016 TAMIFLU oseltamivir phosphate REMOVE UM: CUSTOM Max 20 per 180 days
12/28/2016 TAMIFLU oseltamivir phosphate REMOVE UM: QUANTITY 10 / rx
12/28/2016 oseltamivir phosphate
oseltamivir phosphate ADD TO FORMULARY Covered
12/28/2016 oseltamivir phosphate
oseltamivir phosphate ADD UM: QUANTITY 10 / rx
12/28/2016 oseltamivir phosphate
oseltamivir phosphate ADD UM: CUSTOM Max 20 per 180 days
12/28/2016 TAMIFLU oseltamivir phosphate REMOVE FROM FORMULARY
Covered Non-Formulary
12/28/2016 TAMIFLU oseltamivir phosphate REMOVE UM: CUSTOM Max 20 per 180 days
12/28/2016 TAMIFLU oseltamivir phosphate REMOVE UM: QUANTITY 10 / rx
12/28/2016 oseltamivir phosphate
oseltamivir phosphate ADD TO FORMULARY Covered
12/28/2016 oseltamivir phosphate
oseltamivir phosphate ADD UM: QUANTITY 20 / rx
12/28/2016 oseltamivir phosphate
oseltamivir phosphate ADD UM: CUSTOM Max 40 per 180 days
12/28/2016 TAMIFLU oseltamivir phosphate REMOVE FROM FORMULARY
Covered Non-Formulary
12/28/2016 TAMIFLU oseltamivir phosphate REMOVE UM: CUSTOM Max 40 per 180 days
12/28/2016 TAMIFLU oseltamivir phosphate REMOVE UM: QUANTITY 20 / rx
12/31/2016 FLUMIST QUAD 2015-2016
influenza vaccine quadrivalent live 2015-2016 (2 yrs-49 yrs)
REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 213 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
12/31/2016 FLUCELVAX 2015-2016
influenza vaccine trivalent 2015-16(18 yr,up)cell derived/pf
REMOVE FROM FORMULARY
Covered Non-Formulary
12/31/2016 EZ FLU 2015- 2016 (FLUCELVAX)
influenza vaccine trivalent 2015-16(18 yr,up)cell derived/pf
REMOVE FROM FORMULARY
Covered Non-Formulary
12/31/2016 FLUZONE QUAD PEDI 2015-2016
influenza virus vaccine quadrival 2015-16 (6 mos- 35 mos)/pf
REMOVE FROM FORMULARY
Covered Non-Formulary
12/31/2016 FLULAVAL QUAD 2015- 2016
influenza virus vaccine quadrival 2015-2016 (36 mos, older)
REMOVE FROM FORMULARY
Covered Non-Formulary
12/31/2016 FLUZONE QUAD 2015-2016
influenza virus vaccine quadrival split2015-16(36 mos,up)/pf
REMOVE FROM FORMULARY
Covered Non-Formulary
12/31/2016 FLUARIX QUAD 2015-2016
influenza virus vaccine quadrival split2015-16(36 mos,up)/pf
REMOVE FROM FORMULARY
Covered Non-Formulary
12/31/2016 FLUZONE INTRADERM QUAD 2015-16
influenza virus vaccine quadrivalent 2015-16(18yrs- 64yrs)/pf
REMOVE FROM FORMULARY
Covered Non-Formulary
12/31/2016 FLUZONE QUAD 2015-2016
influenza virus vaccine qvalsplit 2015-2016(6 mos and older)
REMOVE FROM FORMULARY
Covered Non-Formulary
12/31/2016 FLUZONE 2015- 2016
influenza virus vaccine trivalent 2015-16 (6 mos and older)
REMOVE FROM FORMULARY
Covered Non-Formulary
12/31/2016 FLUVIRIN 2015- 2016
influenza virus vaccine trivalent 2015-2016 (4 yr and older)
REMOVE FROM FORMULARY
Covered Non-Formulary
12/31/2016 AFLURIA 2015- 2016
influenza virus vaccine trivalent 2015-2016 (5 yr and older)
REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 214 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
12/31/2016 FLUZONE HIGH- DOSE 2015-2016
influenza virus vaccine trivalent split 2015-16(65 yr,up)/pf
REMOVE FROM FORMULARY
Covered Non-Formulary
12/31/2016 FLUVIRIN 2015- 2016
influenza virus vaccine trivalent 2015-2016 (4 yr, older)/pf
REMOVE FROM FORMULARY
Covered Non-Formulary
12/31/2016 EZ FLU 2015- 2016 (FLUVIRIN)
influenza virus vaccine trivalent 2015-2016 (4 yr, older)/pf
REMOVE FROM FORMULARY
Covered Non-Formulary
12/31/2016 FLUZONE QUAD 2015-2016
influenza virus vaccine quadrival split2015-16(36 mos,up)/pf
REMOVE FROM FORMULARY
Covered Non-Formulary
12/31/2016 AFLURIA 2015- 2016
influenza virus vaccine trivalnt 2015-2016 (5 yr, older)/pf
REMOVE FROM FORMULARY
Covered Non-Formulary
12/31/2016 FLUBLOK 2015- 2016
influenza virus vaccine tv 2015-2016(18 yrs, older)recomb/pf
REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 215 UPDATED 10/2018
January, 2017
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2017 PRED MILD prednisolone acetate ADD UM: QUANTITY 10 / 30 days 01/01/2017 timolol maleate timolol maleate ADD UM: QUANTITY 10 / 30 days 01/01/2017 timolol maleate timolol maleate ADD UM: QUANTITY 10 / 30 days 01/01/2017 apraclonidine hcl apraclonidine hcl ADD UM: QUANTITY 10 / 30 days 01/01/2017 brimonidine
tartrate brimonidine tartrate ADD UM: QUANTITY 10 / 30 days
01/01/2017 azelastine hcl azelastine hcl ADD UM: QUANTITY 6 / 30 days 01/01/2017 aspirin,children's
aspirin,st joseph aspirin,bayer chewable aspirin,baby aspirin,st. joseph aspirin
aspirin REMOVE UM: AGE
01/01/2017 aspirin ec,ecotrin,low dose aspirin ec,aspir-low,lo- dose aspirin ec,adult low dose aspirin ec,miniprin,halfpri n,aspir 81,st. joseph aspirin ec,adult low strength aspirin,aspirin,st joseph aspirin,adult low strength
aspirin REMOVE UM: AGE
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 216 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
01/01/2017 ketone test strip,ketostix reagent,diascree n 1k reagent,ketone care test strip,chemstrip k,trueplus ketone test strip,ketocare
urine acetone test,strips ADD TO FORMULARY Covered
01/01/2017 cleocin,clindamyc in phosphate,clinda max
clindamycin phosphate REMOVE UM: QUANTITY 40 / fill
01/01/2017 vandazole,metro nidazole,metrogel -vaginal
metronidazole REMOVE UM: QUANTITY
01/01/2017 ciloxan,ciprofloxa cin hcl
ciprofloxacin hcl CHANGE UM: QUANTITY 2 / 1 days 10 / 30 days
01/01/2017 expecta lipil,dha complete,prenata l dha,dha prenatal,algal omega-3 dha
docosahexanoic acid ADD TO FORMULARY Covered
01/01/2017 fish oil concentrate,supe r omega- 3,omega-3
omega-3 fatty acids ADD TO FORMULARY Covered
01/01/2017 fish oil,omega-3 fish oil,omega-3
omega-3 fatty acids/docosahexanoic acid/epa/fish oil,omega-3 fatty acids/vitamin e
ADD TO FORMULARY Covered
01/01/2017 fish oil ultra,omega 3
omega-3 fatty acids/docosahexanoic acid/epa/fish oil
ADD TO FORMULARY Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 217 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
01/01/2017 fish oil,fish oil omega-3,fish oil concentrate,ome ga-3 fish oil
omega-3 fatty acids/fish oil,omega-3 fatty acids/docosahexanoic acid/epa/fish oil
ADD TO FORMULARY Covered
01/01/2017 fish oil omega-3 fatty acids/docosahexanoic acid/epa/fish oil
ADD TO FORMULARY Covered
01/01/2017 fish oil,omega-3 fish oil
omega-3 fatty acids/docosahexanoic acid/epa/fish oil
ADD TO FORMULARY Covered
01/01/2017 fish oil omega-3 fatty acids/docosahexanoic acid/epa/fish oil
ADD TO FORMULARY Covered
01/01/2017 fish oil omega-3 fatty acids/fish oil ADD TO FORMULARY Covered 01/01/2017 fish oil omega-3 fatty acids/fish
oil,omega-3 fatty acids/docosahexanoic acid/epa/fish oil
ADD TO FORMULARY Covered
01/01/2017 omega-3 fish oil omega-3 fatty acids/docosahexanoic acid/epa/fish oil
ADD TO FORMULARY Covered
01/01/2017 fish oil,fish oil omega-3
omega-3 fatty acids/fish oil,omega-3 fatty acids/dha/epa/other omega- 3s/fish oil
ADD TO FORMULARY Covered
01/01/2017 sea-omega 30,fish oil omega- 3,fish oil,theragran-m
omega-3 fatty acids/fish oil ADD TO FORMULARY Covered
01/01/2017 SEA-OMEGA 30 omega-3 fatty acids/fish oil REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 218 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
01/01/2017 fish oil,omega-3 fish oil
omega-3 fatty acids/docosahexanoic acid/epa/fish oil
ADD TO FORMULARY Covered
01/01/2017 fish oil omega-3 fatty acids/fish oil,omega-3 fatty acids/docosahexanoic acid/epa/fish oil
ADD TO FORMULARY Covered
01/01/2017 valsartan- hydrochlorothiazi de
valsartan/hydrochlorothiazid e
ADD TO FORMULARY Covered
01/01/2017 valsartan- hydrochlorothiazi de
valsartan/hydrochlorothiazid e
ADD TO FORMULARY Covered
01/01/2017 SEA-OMEGA 30 omega-3 fatty acids/fish oil ADD TO FORMULARY Non-Formulary Covered 01/01/2017 rosuvastatin
calcium rosuvastatin calcium ADD TO FORMULARY Covered
01/01/2017 rosuvastatin calcium
rosuvastatin calcium ADD UM: QUANTITY 1 / 1 days
01/01/2017 rosuvastatin calcium
rosuvastatin calcium ADD TO FORMULARY Covered
01/01/2017 rosuvastatin calcium
rosuvastatin calcium ADD UM: QUANTITY 1 / 1 days
01/01/2017 rosuvastatin calcium
rosuvastatin calcium ADD TO FORMULARY Covered
01/01/2017 rosuvastatin calcium
rosuvastatin calcium ADD UM: QUANTITY 1 / 1 days
01/01/2017 rosuvastatin calcium
rosuvastatin calcium ADD TO FORMULARY Covered
01/01/2017 rosuvastatin calcium
rosuvastatin calcium ADD UM: QUANTITY 1 / 1 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 219 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
01/12/2017 dolophine hcl,methadone hcl,methadose
methadone hcl CHANGE UM: QUANTITY 4 / days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 220 UPDATED 10/2018
February, 2017
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/01/2017 acetaminophen-
codeine acetaminophen with codeine phosphate
CHANGE UM: QUANTITY 2 / Day 240 / 30 days
02/01/2017 nasal allergy triamcinolone acetonide ADD TO FORMULARY Covered 02/01/2017 NASACORT AQ triamcinolone acetonide ADD TO FORMULARY Non-Formulary Not Covered 02/01/2017 triamcinolone
acetonide triamcinolone acetonide CHANGE TIER Not Covered
02/01/2017 triamcinolone acetonide
triamcinolone acetonide ADD UM: CUSTOM OTC Cov'd
02/01/2017 albuterol sulfate albuterol sulfate REMOVE FROM FORMULARY
Covered Non-Formulary
02/01/2017 albuterol sulfate albuterol sulfate REMOVE FROM FORMULARY
Covered Non-Formulary
02/01/2017 cetirizine hcl cetirizine hcl REMOVE FROM FORMULARY
Covered Non-Formulary
02/01/2017 cetirizine hcl cetirizine hcl REMOVE UM: AGE 0 to 12 yrs old
02/01/2017 cetirizine hcl cetirizine hcl REMOVE UM: QUANTITY 1 / Day
02/01/2017 children's cetirizine hcl
cetirizine hcl REMOVE FROM FORMULARY
Covered Non-Formulary
02/01/2017 children's cetirizine hcl
cetirizine hcl REMOVE UM: AGE 0 to 12 yrs old
02/01/2017 children's cetirizine hcl
cetirizine hcl REMOVE UM: QUANTITY 1 / Day
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 221 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
02/01/2017 children's wal- zyr,cetirizine hcl,all day allergy,children's cetirizine hcl,children's zyrtec,zyrtec,chil dren's allergy relief,allergy relief
cetirizine hcl REMOVE FROM FORMULARY
Covered Non-Formulary
02/01/2017 children's wal- zyr,cetirizine hcl,all day allergy,children's cetirizine hcl,children's zyrtec,zyrtec,chil dren's allergy relief,allergy relief
cetirizine hcl REMOVE UM: AGEQUANTITY
Up to 12 yrs old; 1 / day
02/01/2017 children's wal- zyr,cetirizine hcl,all day allergy,children's cetirizine hcl,children's zyrtec,zyrtec,chil dren's allergy relief,allergy relief
cetirizine hcl REMOVE UM: AGE 0 to 12 yrs old
02/01/2017 children's wal- zyr,cetirizine hcl,all day allergy,children's cetirizine hcl,children's zyrtec,zyrtec,chil dren's allergy relief,allergy relief
cetirizine hcl REMOVE UM: QUANTITY 1 / Day
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 222 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
02/01/2017 miconazole 3 miconazole nitrate REMOVE FROM FORMULARY
Covered Non-Formulary
02/01/2017 miconazole 3 miconazole nitrate REMOVE UM: GENDER Female
02/01/2017 POTABA potassium aminobenzoate REMOVE FROM FORMULARY
Covered Non-Formulary
02/01/2017 eryped 200,e.e.s. 200,erythromycin ethylsuccinate
erythromycin ethylsuccinate REMOVE FROM FORMULARY
Non-Formulary
02/01/2017 eryped 200,e.e.s. 200,erythromycin ethylsuccinate
erythromycin ethylsuccinate REMOVE UM: AGE
02/01/2017 eryped 200,e.e.s. 200,erythromycin ethylsuccinate
erythromycin ethylsuccinate REMOVE UM: QUANTITY
02/01/2017 erythromycin ethylsuccinate
erythromycin ethylsuccinate REMOVE FROM FORMULARY
Covered Non-Formulary
02/01/2017 erythromycin erythromycin base REMOVE FROM FORMULARY
Covered Non-Formulary
02/01/2017 erythromycin,eryt hromycin stearate
erythromycin base,erythromycin stearate
REMOVE FROM FORMULARY
Covered Non-Formulary
02/01/2017 erythromycin erythromycin base REMOVE FROM FORMULARY
Covered Non-Formulary
02/01/2017 terazol 3,terconazole,zaz ole
terconazole REMOVE FROM FORMULARY
Non-Formulary
02/01/2017 terazol 3,terconazole,zaz ole
terconazole REMOVE UM: GENDER Female
02/01/2017 doxycycline monohydrate
doxycycline monohydrate REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 223 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
02/01/2017 monodox,doxycy cline monohydrate,mo ndoxyne nl
doxycycline monohydrate REMOVE FROM FORMULARY
Non-Formulary
02/01/2017 clotrimazole- betamethasone
clotrimazole/betamethasone dipropionate
ADD TO FORMULARY Covered
02/01/2017 clotrimazole- betamethasone
clotrimazole/betamethasone dipropionate
ADD UM: QUANTITY 45 / 30 days
02/01/2017 doxycycline monohydrate
doxycycline monohydrate ADD TO FORMULARY Covered
02/01/2017 THALOMID thalidomide ADD TO FORMULARY Covered 02/01/2017 CIPRODEX ciprofloxacin
hcl/dexamethasone ADD UM: QUANTITY 7.5 / 30 days
02/01/2017 CIPRODEX ciprofloxacin hcl/dexamethasone
REMOVE UM: AGE Up to 12 yrs old
02/01/2017 levofloxacin levofloxacin ADD TO FORMULARY Covered 02/01/2017 levofloxacin levofloxacin ADD UM: AGE 0 to 12 yrs old 02/01/2017 ciprofloxacin hcl ciprofloxacin hcl ADD TO FORMULARY Covered 02/01/2017 THALOMID thalidomide ADD TO FORMULARY Covered 02/01/2017 THALOMID thalidomide ADD UM: AUTHORIZATION PA applies
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 224 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
02/01/2017 miranel af,antifungal cream,miconazol e nitrate,micro- guard,baza antifungal,secura antifungal,anti- fungal,inzo antifungal,anti- fungal cream,monistat- derm,micaderm, micatin,nuzole,ne osporin af,theracure
miconazole nitrate ADD TO FORMULARY Covered
02/01/2017 KITABIS PAK tobramycin/nebulizer ADD TO FORMULARY Covered 02/01/2017 tetracycline hcl tetracycline hcl REMOVE UM: AGE
02/01/2017 tetracycline hcl tetracycline hcl REMOVE UM: AGE
02/01/2017 doxycycline monohydrate
doxycycline monohydrate ADD TO FORMULARY Covered
02/01/2017 avidoxy doxycycline monohydrate ADD TO FORMULARY Covered 02/01/2017 isoniazid isoniazid ADD UM: QUANTITY 0 / 12 days 02/01/2017 tavist-
1,clemastine fumarate,allergy relief,dailyhist- 1,dayhist allergy,allerhist- 1,dayhist,dayhist- 1
clemastine fumarate REMOVE UM: QUANTITY 1 / Day
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 225 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
02/01/2017 desenex,lamisil at,athlete's foot,antifungal,ter binafine,athlete's foot af,jock itch,lamisil,foot antifungal
terbinafine hcl,clotrimazole ADD TO FORMULARY Covered
02/01/2017 ivermectin ivermectin ADD TO FORMULARY Covered 02/01/2017 THALOMID thalidomide ADD TO FORMULARY Covered 02/01/2017 THALOMID thalidomide ADD TO FORMULARY Covered 02/01/2017 THALOMID thalidomide ADD UM: AUTHORIZATION PA applies 02/01/2017 THALOMID thalidomide ADD UM: AUTHORIZATION PA applies 02/01/2017 PIN-X pyrantel pamoate ADD TO FORMULARY Covered 02/01/2017 isoniazid isoniazid ADD UM: AGE 0 to 12 yrs old 02/01/2017 isoniazid isoniazid REMOVE UM: QUANTITY 0 / 12 days
02/01/2017 THALOMID thalidomide REMOVE UM: AUTHORIZATION
PA applies
02/01/2017 triamcinolone acetonide
triamcinolone acetonide CHANGE TIER Not Covered Covered
02/01/2017 nasal allergy triamcinolone acetonide ADD UM: CUSTOM OTC ONLY 02/01/2017 NASACORT triamcinolone acetonide REMOVE UM: QUANTITY 16.9 / 30 days
02/01/2017 CHILDREN'S NASACORT
triamcinolone acetonide REMOVE UM: QUANTITY 16.9 / 30 days
02/01/2017 THALOMID thalidomide REMOVE UM: AUTHORIZATION
PA applies
02/01/2017 THALOMID thalidomide REMOVE UM: AUTHORIZATION
PA applies
02/01/2017 NASACORT AQ triamcinolone acetonide REMOVE FROM FORMULARY
Not Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 226 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
02/01/2017 QVAR REDIHALER
beclomethasone dipropionate
ADD TO FORMULARY Covered
02/01/2017 QVAR REDIHALER
beclomethasone dipropionate
ADD UM: QUANTITY 10.6 / 30 days
02/01/2017 QVAR REDIHALER
beclomethasone dipropionate
ADD TO FORMULARY Covered
02/01/2017 QVAR REDIHALER
beclomethasone dipropionate
ADD UM: QUANTITY 10.6 / 30 days
02/01/2017 QVAR REDIHALER
beclomethasone dipropionate
REMOVE FROM FORMULARY
Covered Non-Formulary
02/01/2017 QVAR REDIHALER
beclomethasone dipropionate
REMOVE FROM FORMULARY
Covered Non-Formulary
02/01/2017 QVAR REDIHALER
beclomethasone dipropionate
REMOVE UM: QUANTITY 10.6 / 30 days
02/01/2017 QVAR REDIHALER
beclomethasone dipropionate
REMOVE UM: QUANTITY 10.6 / 30 days
02/15/2017 OCUVITE LUTEIN & ZEAXANTHIN
vit c/vit e acetate/zinc oxid/cupric oxide/lutein/zeaxanthin
REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 227 UPDATED 10/2018
March, 2017
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2017 selenium sulfide selenium sulfide REMOVE FROM
FORMULARY Covered Non-Formulary
03/01/2017 erythromycin- benzoyl peroxide
erythromycin base/benzoyl peroxide
REMOVE FROM FORMULARY
Non-Formulary
03/01/2017 glucotrol,glipizide glipizide REMOVE UM: QUANTITY
03/01/2017 glucotrol xl,glipizide er,glipizide xl
glipizide REMOVE UM: QUANTITY
03/01/2017 sodium sulfacetamide- sulfur,sulfacetami de sodium-sulfur
sulfacetamide sodium/sulfur ADD TO FORMULARY Covered
03/01/2017 rosanil sulfacetamide sodium/sulfur ADD TO FORMULARY Covered 03/01/2017 avar sulfacetamide sodium/sulfur ADD TO FORMULARY Covered 03/01/2017 panoxyl-4 benzoyl peroxide ADD TO FORMULARY Covered 03/01/2017 creamy acne face benzoyl peroxide ADD TO FORMULARY Covered 03/01/2017 selenium sulfide selenium sulfide ADD TO FORMULARY Non-Formulary Covered 03/01/2017 betamethasone
dipropionate betamethasone dipropionate ADD TO FORMULARY Covered
03/01/2017 betamethasone dipropionate
betamethasone dipropionate ADD UM: QUANTITY 60 / 30 days
03/01/2017 betamethasone dipropionate
betamethasone dipropionate ADD TO FORMULARY Covered
03/01/2017 betamethasone dipropionate
betamethasone dipropionate ADD UM: QUANTITY 45 / 30 days
03/01/2017 fluticasone propionate
fluticasone propionate ADD TO FORMULARY Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 228 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
03/01/2017 fluticasone propionate
fluticasone propionate ADD UM: QUANTITY 45 / 30 days
03/01/2017 fluticasone propionate
fluticasone propionate ADD TO FORMULARY Covered
03/01/2017 fluticasone propionate
fluticasone propionate ADD UM: QUANTITY 60 / 30 days
03/01/2017 mometasone furoate
mometasone furoate CHANGE UM: QUANTITY 1.67 / 1 days 45 / 30 days
03/01/2017 mometasone furoate
mometasone furoate ADD TO FORMULARY Covered
03/01/2017 mometasone furoate
mometasone furoate ADD UM: QUANTITY 45 / 30 days
03/01/2017 GLUCAGEN glucagon,human recombinant
ADD UM: QUANTITY 1 / 30 days
03/01/2017 TRADJENTA linagliptin ADD UM: QUANTITY 1 / days 03/01/2017 TRADJENTA linagliptin REMOVE UM:
AUTHORIZATION PA applies
03/01/2017 glucovance,glybu ride-metformin hcl
glyburide/metformin hcl REMOVE UM: QUANTITY
03/01/2017 glucovance,glybu ride-metformin hcl
glyburide/metformin hcl REMOVE UM: QUANTITY
03/01/2017 chlorpropamide chlorpropamide REMOVE UM: QUANTITY 4 / Day
03/01/2017 chlorpropamide chlorpropamide REMOVE UM: QUANTITY 3 / Day
03/01/2017 amaryl,glimepirid e
glimepiride REMOVE UM: QUANTITY
03/01/2017 amaryl,glimepirid e
glimepiride REMOVE UM: QUANTITY
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 229 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
03/01/2017 amaryl,glimepirid e,naproxen sodium
glimepiride,naproxen sodium
REMOVE UM: QUANTITY
03/01/2017 glucotrol xl,glipizide er,glipizide xl
glipizide REMOVE UM: QUANTITY
03/01/2017 glucotrol xl,glipizide er,glipizide xl
glipizide REMOVE UM: QUANTITY
03/01/2017 diabeta,glyburide, micronase
glyburide REMOVE UM: QUANTITY
03/01/2017 diabeta,glyburide, micronase
glyburide REMOVE UM: QUANTITY
03/01/2017 micronase,diabet a,glyburide
glyburide REMOVE UM: QUANTITY
03/01/2017 glynase,glyburide micronized
glyburide,micronized REMOVE UM: QUANTITY
03/01/2017 glynase,glyburide micronized
glyburide,micronized REMOVE UM: QUANTITY
03/01/2017 glynase,glyburide micronized
glyburide,micronized REMOVE UM: QUANTITY
03/01/2017 JENTADUETO linagliptin/metformin hcl ADD UM: QUANTITY 2 / 1 days 03/01/2017 JENTADUETO linagliptin/metformin hcl REMOVE UM:
AUTHORIZATION PA applies
03/01/2017 JENTADUETO linagliptin/metformin hcl ADD UM: QUANTITY 2 / 1 days 03/01/2017 JENTADUETO linagliptin/metformin hcl REMOVE UM:
AUTHORIZATION PA applies
03/01/2017 JENTADUETO linagliptin/metformin hcl ADD UM: QUANTITY 2 / 1 days 03/01/2017 JENTADUETO linagliptin/metformin hcl REMOVE UM:
AUTHORIZATION PA applies
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 230 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
03/01/2017 prochlorperazine maleate
prochlorperazine maleate CHANGE UM: QUANTITY 1 / Day 4 / 1 days
03/01/2017 COMPAZINE prochlorperazine maleate REMOVE UM: QUANTITY 1 / Day
03/01/2017 prochlorperazine maleate
prochlorperazine maleate CHANGE UM: QUANTITY 1 / Day 4 / 1 days
03/01/2017 COMPAZINE prochlorperazine maleate REMOVE UM: QUANTITY 1 / Day
03/01/2017 ZOFRAN ondansetron hcl REMOVE UM: QUANTITY 5 / Day
03/01/2017 ondansetron hcl ondansetron hcl CHANGE UM: QUANTITY 5 / Day 10 / 1 days 03/01/2017 CREON lipase/protease/amylase CHANGE UM: QUANTITY 336 / days 720 / 30 days 03/01/2017 ZENPEP lipase/protease/amylase ADD UM: QUANTITY 720 / 30 days 03/01/2017 PANCREAZE lipase/protease/amylase ADD UM: QUANTITY 720 / 30 days 03/01/2017 pancrelipase
5,000 lipase/protease/amylase ADD UM: QUANTITY 720 / 30 days
03/01/2017 CREON lipase/protease/amylase CHANGE UM: QUANTITY 168 / days 720 / 30 days 03/01/2017 ZENPEP lipase/protease/amylase ADD UM: QUANTITY 720 / 30 days 03/01/2017 PANCREAZE lipase/protease/amylase ADD UM: QUANTITY 480 / 30 days 03/01/2017 CREON lipase/protease/amylase CHANGE UM: QUANTITY 90 / days 480 / 30 days 03/01/2017 ZENPEP lipase/protease/amylase ADD UM: QUANTITY 480 / 30 days 03/01/2017 PANCREAZE lipase/protease/amylase ADD UM: QUANTITY 480 / 30 days 03/01/2017 PANCREAZE lipase/protease/amylase ADD UM: QUANTITY 480 / 30 days 03/01/2017 ZENPEP lipase/protease/amylase ADD UM: QUANTITY 480 / 30 days 03/01/2017 CREON lipase/protease/amylase CHANGE UM: QUANTITY 42 / days 480 / 30 days 03/01/2017 ZENPEP lipase/protease/amylase ADD UM: QUANTITY 480 / 30 days 03/01/2017 CREON lipase/protease/amylase CHANGE UM: QUANTITY 28 / days 480 / 30 days 03/01/2017 milk of magnesia magnesium hydroxide CHANGE TIER Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 231 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
03/01/2017 magnesium citrate
magnesium citrate CHANGE TIER Covered
03/01/2017 magnesium citrate,citroma,citr ate of magnesia
magnesium citrate CHANGE TIER Covered
03/01/2017 DULCOLAX bisacodyl REMOVE FROM FORMULARY
Covered Non-Formulary
03/01/2017 doxidan,laxative, bisacodyl,reliable gentle laxative,gentle laxative,dulcolax, bisac- evac,women's laxative,women's gentle laxative,woman's laxative,bisa- lax,alophen pills,stimulant laxative,ducodyl
bisacodyl REMOVE UM: QUANTITY
03/01/2017 alfuzosin hcl er alfuzosin hcl ADD TO FORMULARY Covered 03/01/2017 OXYTROL FOR
WOMEN oxybutynin ADD TO FORMULARY Covered
03/01/2017 alogliptin- pioglitazone
alogliptin benzoate/pioglitazone hcl
ADD UM: QUANTITY 1 / 1 days
03/01/2017 alogliptin- pioglitazone
alogliptin benzoate/pioglitazone hcl
ADD UM: QUANTITY 1 / 1 days
03/01/2017 alogliptin- pioglitazone
alogliptin benzoate/pioglitazone hcl
ADD UM: QUANTITY 1 / 1 days
03/01/2017 alogliptin- pioglitazone
alogliptin benzoate/pioglitazone hcl
ADD UM: QUANTITY 1 / 1 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 232 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
03/01/2017 alogliptin- pioglitazone
alogliptin benzoate/pioglitazone hcl
ADD UM: QUANTITY 1 / 1 days
03/01/2017 PANCREAZE lipase/protease/amylase ADD UM: QUANTITY 720 / 30 days 03/01/2017 fish oil omega-3 fatty
acids/docosahexanoic acid/epa/fish oil
ADD TO FORMULARY Covered
03/01/2017 metronidazole metronidazole ADD TO FORMULARY Covered 03/01/2017 rosadan metronidazole ADD TO FORMULARY Covered 03/02/2017 CREON lipase/protease/amylase CHANGE UM: QUANTITY 480 / 30 days 720 / 30 days 03/02/2017 CREON lipase/protease/amylase CHANGE UM: QUANTITY 480 / 30 days 720 / 30 days 03/02/2017 pancrelipase
5,000,zenpep lipase/protease/amylase CHANGE UM: QUANTITY 720 / 30 days
03/02/2017 ZENPEP lipase/protease/amylase CHANGE UM: QUANTITY 480 / 30 days 720 / 30 days 03/02/2017 CREON lipase/protease/amylase CHANGE UM: QUANTITY 720 / 30 days 480 / 30 days 03/02/2017 ZENPEP lipase/protease/amylase CHANGE UM: QUANTITY 720 / 30 days 480 / 30 days 03/02/2017 PANCREAZE lipase/protease/amylase CHANGE UM: QUANTITY 720 / 30 days 480 / 30 days 03/03/2017 CREON lipase/protease/amylase CHANGE UM: QUANTITY 480 / 30 days 720 / 30 days 03/03/2017 ZENPEP lipase/protease/amylase CHANGE UM: QUANTITY 480 / 30 days 720 / 30 days 03/03/2017 PANCREAZE lipase/protease/amylase CHANGE UM: QUANTITY 480 / 30 days 720 / 30 days 03/03/2017 CREON lipase/protease/amylase CHANGE UM: QUANTITY 720 / 30 days 480 / 30 days 03/03/2017 ZENPEP lipase/protease/amylase CHANGE UM: QUANTITY 720 / 30 days 480 / 30 days 03/03/2017 CREON lipase/protease/amylase CHANGE UM: QUANTITY 720 / 30 days 480 / 30 days 03/10/2017 gengraf,neoral,cy
closporine modified,cyclosp orine
cyclosporine, modified REMOVE UM: QUANTITY
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 233 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
03/13/2017 gentle laxative,bisacodyl ,bisac- evac,biscolax,lax ative suppository,fast relief laxative,dulcolax, magic bullet
bisacodyl REMOVE UM: QUANTITY
03/14/2017 enulose,lactulose ,generlac
lactulose CHANGE TIER Not Covered
03/14/2017 lactulose lactulose ADD TO FORMULARY Covered 03/14/2017 theophylline theophylline anhydrous CHANGE TIER Covered 03/14/2017 lactulose lactulose CHANGE TIER Covered 03/14/2017 VENOFER iron sucrose complex REMOVE FROM
FORMULARY Covered Non-Formulary
03/14/2017 pin-x pyrantel pamoate ADD TO FORMULARY Covered 03/14/2017 methotrexate methotrexate sodium ADD TO FORMULARY Covered 03/14/2017 methotrexate
sodium,methotre xate
methotrexate sodium/pf ADD TO FORMULARY Covered
03/14/2017 hydrocodone- acetaminophen
hydrocodone bitartrate/acetaminophen
REMOVE FROM FORMULARY
Covered Non-Formulary
03/14/2017 calcium 600 + vitamin d,calcium 600-vit d3,liquid calcium 600-vit d3
calcium carbonate/cholecalciferol (vitamin d3)
REMOVE FROM FORMULARY
Covered Non-Formulary
03/14/2017 vancomycin hcl vancomycin hcl REMOVE FROM FORMULARY
Non-Formulary
03/14/2017 vancomycin hcl vancomycin hcl REMOVE FROM FORMULARY
Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 234 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
03/14/2017 KIONEX sodium polystyrene sulfonate/sorbitol solution
REMOVE FROM FORMULARY
Covered Non-Formulary
03/14/2017 covaryx estrogens,esterified/methylt estosterone
REMOVE FROM FORMULARY
Covered Non-Formulary
03/14/2017 covaryx h.s. estrogens,esterified/methylt estosterone
REMOVE FROM FORMULARY
Covered Non-Formulary
03/15/2017 enulose lactulose REMOVE FROM FORMULARY
Not Covered Non-Formulary
03/15/2017 generlac lactulose REMOVE FROM FORMULARY
Not Covered Non-Formulary
03/15/2017 lactulose lactulose REMOVE FROM FORMULARY
Non-Formulary
03/16/2017 lactulose lactulose ADD TO FORMULARY Covered 03/21/2017 estrogen &
methyltestosteron e,estrogen- methyltestosteron e
estrogens,esterified/methylt estosterone
REMOVE FROM FORMULARY
Covered Non-Formulary
03/21/2017 estrogen- methyltestosteron e,estrogen & methyltestosteron e
estrogens,esterified/methylt estosterone
REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 235 UPDATED 10/2018
April, 2017
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/01/2017 flurbiprofen flurbiprofen ADD TO FORMULARY Covered 04/01/2017 TRI-VI-SOL vitamin a palmitate/ascorbic
acid/cholecalciferol (vit d3) ADD TO FORMULARY Covered
04/01/2017 prenatal complete
prenatal vits with calcium no.21/ferrous fumarate/folic acid
ADD TO FORMULARY Covered
04/01/2017 prenatal 19 prenatal vits no.119/iron fumarate/folic acid/docusate sod.,prenatal vits no.115/iron fumarate/folic acid/docusate sod.
ADD TO FORMULARY Covered
04/01/2017 THRIVITE 19 multivit-mins no.59/ferrous fumarate/folic acid/docusate sod
ADD TO FORMULARY Covered
04/01/2017 pilocarpine hcl pilocarpine hcl ADD TO FORMULARY Covered 04/01/2017 LEVO-T levothyroxine sodium ADD TO FORMULARY Covered 04/01/2017 liothyronine
sodium liothyronine sodium ADD TO FORMULARY Covered
04/01/2017 liothyronine sodium
liothyronine sodium ADD TO FORMULARY Covered
04/01/2017 liothyronine sodium
liothyronine sodium ADD TO FORMULARY Covered
04/01/2017 SYSTANE GEL propylene glycol/polyethylene glycol 400
ADD TO FORMULARY Covered
04/01/2017 DIALYVITE VITAMIN D3 MAX
cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 236 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
04/01/2017 prenatal prenatal vitamins no.62/folic acid/omega-3s/dha/epa/fish oil
ADD TO FORMULARY Covered
04/01/2017 se-natal 19 prenatal vits no.119/iron fumarate/folic acid/docusate sod.
ADD TO FORMULARY Covered
04/01/2017 cyanocobalamin injection
cyanocobalamin (vitamin b- 12)
ADD TO FORMULARY Covered
04/01/2017 decara cholecalciferol (vitamin d3) ADD TO FORMULARY Covered 04/01/2017 optimal d3 cholecalciferol (vitamin d3) ADD TO FORMULARY Covered 04/01/2017 REFRESH
LACRI-LUBE mineral oil/petrolatum,white ADD TO FORMULARY Covered
04/01/2017 lubricant eye,lubricant pm
mineral oil/petrolatum,white ADD TO FORMULARY Covered
04/01/2017 lubricant eye,lubricating tears
propylene glycol/polyethylene glycol 400
ADD TO FORMULARY Covered
04/01/2017 ultra lubricant eye propylene glycol/polyethylene glycol 400
ADD TO FORMULARY Covered
04/01/2017 lubricating relief propylene glycol/polyethylene glycol 400
ADD TO FORMULARY Covered
04/01/2017 ultra fresh carboxymethylcellulose sodium
ADD TO FORMULARY Covered
04/01/2017 lubricant eye drop
carboxymethylcellulose sodium
ADD TO FORMULARY Covered
04/01/2017 moisturizing lubricant
carboxymethylcellulose sodium
ADD TO FORMULARY Covered
04/01/2017 restore tears carboxymethylcellulose sodium
ADD TO FORMULARY Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 237 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
04/01/2017 sodium chloride sodium chloride ADD TO FORMULARY Covered 04/01/2017 sochlor sodium chloride ADD TO FORMULARY Covered 04/01/2017 altachlore sodium chloride ADD TO FORMULARY Covered 04/01/2017 muro-128 sodium chloride ADD TO FORMULARY Covered 04/01/2017 sodium chloride sodium chloride ADD TO FORMULARY Covered 04/01/2017 altachlore sodium chloride ADD TO FORMULARY Covered 04/01/2017 sochlor sodium chloride ADD TO FORMULARY Covered 04/01/2017 lubricant dry eye
relief carboxymethylcellulose sodium
ADD TO FORMULARY Covered
04/01/2017 thera tears carboxymethylcellulose sodium
ADD TO FORMULARY Covered
04/01/2017 sodium fluoride,fluoride
sodium fluoride,fluoride (sodium)
CHANGE TIER Covered
04/01/2017 fluoritab,sodium fluoride,epiflur,lud ent fluoride,fluoride,r enaf,luride,ethed ent,pharmaflur
fluoride (sodium),sodium fluoride
REMOVE UM: QUANTITY
04/01/2017 etodolac etodolac ADD TO FORMULARY Covered 04/01/2017 etodolac etodolac ADD UM: QUANTITY 2 / 1 days 04/01/2017 etodolac etodolac ADD TO FORMULARY Covered 04/01/2017 etodolac etodolac ADD UM: QUANTITY 2 / 1 days 04/01/2017 etodolac etodolac ADD TO FORMULARY Covered 04/01/2017 etodolac etodolac ADD UM: QUANTITY 2 / 1 days 04/01/2017 etodolac etodolac ADD TO FORMULARY Covered 04/01/2017 etodolac etodolac ADD UM: QUANTITY 2 / 1 days 04/01/2017 colchicine colchicine ADD TO FORMULARY Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 238 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
04/01/2017 colchicine colchicine ADD UM: QUANTITY 2 / 1 days 04/01/2017 RANEXA ranolazine ADD UM: AUTHORIZATION PA applies 04/01/2017 RANEXA ranolazine ADD UM: AUTHORIZATION PA applies 04/01/2017 ULORIC febuxostat ADD UM: QUANTITY 1 / 1 days 04/01/2017 ULORIC febuxostat REMOVE UM:
AUTHORIZATION PA applies
04/01/2017 acetazolamide acetazolamide ADD UM: QUANTITY 2 / 1 days 04/01/2017 acetazolamide acetazolamide ADD UM: QUANTITY 4 / 1 days 04/01/2017 acetazolamide acetazolamide ADD UM: QUANTITY 4 / 1 days 04/01/2017 lac-
hydrin,amlactin,a mmonium lactate,geri- hydrolac,lactrex
ammonium lactate REMOVE UM: QUANTITY 4.667 / day
04/01/2017 lac- hydrin,amlactin,la clotion,ammoniu m lactate,lac- hydrin twelve,al- 12,geri- hydrolac,skin treatment,moist skin
ammonium lactate REMOVE UM: QUANTITY 7.5 / day
04/01/2017 chlorhexidine gluconate,periog ard,peridex,paroe x,perisol
chlorhexidine gluconate REMOVE UM: QUANTITY 480 / 30 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 239 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
04/01/2017 prevident,phos- flur,sf,fluoridex daily defense,fluoridex defense whitening,dentag el,thera-flur- n,neutragard advanced,cavare st,neutragard,eth edent
fluoride (sodium),sodium fluoride
ADD TO FORMULARY Covered
04/01/2017 naproxen naproxen CHANGE TIER Not Covered 04/01/2017 calcipotriene calcipotriene CHANGE TIER Covered Not Covered 04/01/2017 UNITHROID levothyroxine sodium CHANGE TIER Covered Not Covered 04/01/2017 UNITHROID levothyroxine sodium CHANGE TIER Covered Not Covered 04/01/2017 OCUVITE
LUTEIN & ZEAXANTHIN
vit c/vit e acetate/zinc oxid/cupric oxide/lutein/zeaxanthin
CHANGE TIER Covered Not Covered
04/01/2017 PRESERVISION AREDS 2
vit c/vit e acetate/zinc oxid/cupric oxide/lutein/zeaxanthin
CHANGE TIER Covered Not Covered
04/01/2017 MACUVITE WITH LUTEIN
beta-carotene/ascorbic acid/vitamin e/lutein/min comb no.29
CHANGE TIER Covered Not Covered
04/01/2017 PROSIGHT vit a/c/e acetate/zinc oxide/sodium selenate/cupric oxide
CHANGE TIER Covered Not Covered
04/01/2017 memory complex ascorbic acid/vitamin e acetate/selenium/ginkgo biloba
CHANGE TIER Covered Not Covered
04/01/2017 MG-PLUS- PROTEIN
magnesium oxide/magnesium amino acid chelate
CHANGE TIER Covered Not Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 240 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
04/01/2017 cerefolin nac,triveen-cf nac,l- methylfolate- mecobalamin- nac,enfolast- n,alz- nac,metafolbic plus,l-methyl-mc nac
acetylcysteine/mecobalamin/levomefolate calcium
CHANGE TIER Covered Not Covered
04/01/2017 methazolamide methazolamide CHANGE TIER Covered Not Covered 04/01/2017 methazolamide methazolamide CHANGE TIER Covered Not Covered 04/01/2017 LEVO-T levothyroxine sodium CHANGE TIER Covered Not Covered 04/01/2017 EPIPEN JR 2-
PAK epinephrine REMOVE FROM
FORMULARY Covered Non-Formulary
04/01/2017 EPIPEN 2-PAK epinephrine REMOVE FROM FORMULARY
Covered Non-Formulary
04/02/2017 decara cholecalciferol (vitamin d3) REMOVE FROM FORMULARY
Covered Non-Formulary
04/02/2017 optimal d3 cholecalciferol (vitamin d3) REMOVE FROM FORMULARY
Covered Non-Formulary
04/02/2017 D3-50 cholecalciferol (vitamin d3) ADD TO FORMULARY Covered 04/02/2017 delta d3 cholecalciferol (vitamin d3) REMOVE FROM
FORMULARY Covered Non-Formulary
04/02/2017 vitamin d3 cholecalciferol (vitamin d3) REMOVE FROM FORMULARY
Non-Formulary
04/02/2017 l-methyl-mc nac acetylcysteine/mecobalamin/levomefolate calcium
REMOVE FROM FORMULARY
Not Covered Non-Formulary
04/02/2017 MACUVITE WITH LUTEIN
beta-carotene/ascorbic acid/vitamin e/lutein/min comb no.29
REMOVE FROM FORMULARY
Not Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 241 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
04/02/2017 metafolbic plus acetylcysteine/mecobalamin/levomefolate calcium
REMOVE FROM FORMULARY
Not Covered Non-Formulary
04/02/2017 methazolamide methazolamide REMOVE FROM FORMULARY
Not Covered Non-Formulary
04/02/2017 MG-PLUS- PROTEIN
magnesium oxide/magnesium amino acid chelate
REMOVE FROM FORMULARY
Not Covered Non-Formulary
04/02/2017 PROSIGHT vit a/c/e acetate/zinc oxide/sodium selenate/cupric oxide
REMOVE FROM FORMULARY
Not Covered Non-Formulary
04/02/2017 UNITHROID levothyroxine sodium REMOVE FROM FORMULARY
Not Covered Non-Formulary
04/02/2017 UNITHROID levothyroxine sodium REMOVE FROM FORMULARY
Not Covered Non-Formulary
04/02/2017 memory complex ascorbic acid/vitamin e acetate/selenium/ginkgo biloba
REMOVE FROM FORMULARY
Not Covered Non-Formulary
04/02/2017 methazolamide methazolamide REMOVE FROM FORMULARY
Not Covered Non-Formulary
04/04/2017 OSENI alogliptin benzoate/pioglitazone hcl
REMOVE FROM FORMULARY
Covered Non-Formulary
04/04/2017 OSENI alogliptin benzoate/pioglitazone hcl
REMOVE FROM FORMULARY
Covered Non-Formulary
04/04/2017 OSENI alogliptin benzoate/pioglitazone hcl
REMOVE FROM FORMULARY
Covered Non-Formulary
04/04/2017 OSENI alogliptin benzoate/pioglitazone hcl
REMOVE FROM FORMULARY
Covered Non-Formulary
04/04/2017 OSENI alogliptin benzoate/pioglitazone hcl
REMOVE FROM FORMULARY
Covered Non-Formulary
04/04/2017 OSENI alogliptin benzoate/pioglitazone hcl
REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 242 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
04/06/2017 naratriptan hcl,amerge,naratr iptan
naratriptan hcl CHANGE UM: CUSTOM Cumulative: 9 tabs per 30 days
across oral statins
CUMULATIVE: 9 TABS PER 30
DAYS ACROSS ORAL
TRIPTANS 04/06/2017 naratriptan
hcl,amerge,naratr iptan
naratriptan hcl CHANGE UM: CUSTOM Cumulative: 9 tabs per 30 days
across oral statins
CUMULATIVE: 9 TABS PER 30
DAYS ACROSS ORAL
TRIPTANS
04/10/2017 naproxen naproxen REMOVE FROM FORMULARY
Not Covered Non-Formulary
04/10/2017 pristiq,desvenlafa xine succinate er
desvenlafaxine succinate CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
04/10/2017 atorvastatin calcium
atorvastatin calcium CHANGE TIER Covered
04/10/2017 atorvastatin calcium
atorvastatin calcium CHANGE UM: QUANTITY 30 / 30 days
04/10/2017 celecoxib celecoxib CHANGE TIER Covered 04/10/2017 celecoxib celecoxib CHANGE UM: QUANTITY 1 / days 04/10/2017 celecoxib celecoxib CHANGE TIER Covered 04/10/2017 celecoxib celecoxib CHANGE UM: QUANTITY 1 / days 04/10/2017 children's pain-
fever acetaminophen CHANGE TIER Covered
04/10/2017 children's pain- fever
acetaminophen CHANGE UM: QUANTITY 125 / days
04/10/2017 cipro,ciprofloxaci n
ciprofloxacin CHANGE UM: AGE Up to 12 yrs old
04/10/2017 clobetasol propionate
clobetasol propionate CHANGE TIER Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 243 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
04/10/2017 clobetasol propionate
clobetasol propionate CHANGE UM: QUANTITY 60 / 30 days
04/10/2017 clonidine hcl clonidine hcl CHANGE TIER Covered 04/10/2017 clotrimazole clotrimazole CHANGE TIER Covered 04/10/2017 epinephrine epinephrine CHANGE TIER Covered 04/10/2017 fentanyl fentanyl CHANGE TIER Covered 04/10/2017 fentanyl fentanyl CHANGE UM: QUANTITY 0.34 / days 04/11/2017 nortrel norethindrone-ethinyl
estradiol CHANGE TIER Covered
04/11/2017 nortrel norethindrone-ethinyl estradiol
CHANGE UM: GENDER Female
04/11/2017 phillips' laxative docusate sodium REMOVE FROM FORMULARY
Covered Non-Formulary
04/19/2017 DRYSOL aluminum chloride ADD TO FORMULARY Non-Formulary Covered 04/21/2017 epinephrine epinephrine CHANGE TIER Covered 04/21/2017 XARELTO rivaroxaban REMOVE UM:
AUTHORIZATION
04/30/2017 NESINA alogliptin benzoate REMOVE FROM FORMULARY
Covered Non-Formulary
04/30/2017 NESINA alogliptin benzoate REMOVE FROM FORMULARY
Covered Non-Formulary
04/30/2017 NESINA alogliptin benzoate REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 244 UPDATED 10/2018
May, 2017
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/02/2017 adapalene,differi
n adapalene CHANGE UM: QUANTITY 45 / 30 days
05/09/2017 nicotine lozenge nicotine polacrilex CHANGE TIER Covered 05/09/2017 nicotine lozenge nicotine polacrilex CHANGE UM: QUANTITY 20 / 1 days 05/09/2017 nicotine lozenge nicotine polacrilex CHANGE TIER Covered 05/09/2017 nicotine lozenge nicotine polacrilex CHANGE UM: QUANTITY 20 / 1 days 05/09/2017 bexarotene bexarotene ADD TO FORMULARY Covered 05/09/2017 TARGRETIN bexarotene REMOVE FROM
FORMULARY Covered Non-Formulary
05/11/2017 DIABETA glyburide REMOVE FROM FORMULARY
Covered Non-Formulary
05/11/2017 glyburide glyburide CHANGE TIER Covered 05/11/2017 glyburide-
metformin hcl glyburide/metformin hcl CHANGE TIER Covered
05/11/2017 glyburide- metformin hcl
glyburide/metformin hcl CHANGE TIER Covered
05/11/2017 glyburide glyburide CHANGE TIER Covered 05/15/2017 TIMOPTIC timolol maleate REMOVE FROM
FORMULARY Covered Non-Formulary
05/15/2017 cosopt,dorzolami de-timolol
dorzolamide hcl/timolol maleate
CHANGE UM: QUANTITY 0.333 / day 0.334 / days
05/16/2017 acular,ketorolac tromethamine
ketorolac tromethamine CHANGE UM: QUANTITY .4 / 1 days 10 / 30 days
05/16/2017 cosopt,dorzolami de-timolol
dorzolamide hcl/timolol maleate
CHANGE UM: QUANTITY 0.334 / days 10 / 30 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 245 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
05/16/2017 trusopt,dorzolami de hcl
dorzolamide hcl CHANGE UM: QUANTITY 0.333 / day 10 / 30 days
05/17/2017 KAZANO alogliptin benzoate/metformin hcl
REMOVE FROM FORMULARY
Covered Non-Formulary
05/17/2017 KAZANO alogliptin benzoate/metformin hcl
REMOVE FROM FORMULARY
Covered Non-Formulary
05/23/2017 nicotine lozenge nicotine polacrilex REMOVE FROM FORMULARY
Non-Formulary
05/30/2017 dovonex,calcipotr iene
calcipotriene REMOVE FROM FORMULARY
Non-Formulary
05/31/2017 LANTUS SOLOSTAR,BAS AGLAR KWIKPEN U-100
insulin glargine,human recombinant analog,insulin glargine, human recombinant analog
ADD UM: QUANTITY 30 / 30 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 246 UPDATED 10/2018
June, 2017
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/01/2017 VIGAMOX moxifloxacin hcl CHANGE UM: QUANTITY 0.1 / day 3 / 30 days 06/02/2017 TANZEUM albiglutide CHANGE UM:
AUTHORIZATION PA applies
06/02/2017 FARXIGA dapagliflozin propanediol CHANGE UM: AUTHORIZATION
PA applies
06/02/2017 pentosan polysulfate sodium,elmiron
pentosan polysulfate sodium CHANGE UM: AUTHORIZATION
PA applies
06/02/2017 ULORIC febuxostat CHANGE UM: AUTHORIZATION
PA applies
06/02/2017 CIALIS,ADCIRC A
tadalafil CHANGE UM: AUTHORIZATION
PA applies
06/05/2017 FARXIGA dapagliflozin propanediol REMOVE UM: AUTHORIZATION
PA applies
06/05/2017 fentanyl,duragesi c,subsys,fentanyl base
fentanyl REMOVE UM: AUTHORIZATION
06/05/2017 INVOKANA canagliflozin REMOVE UM: AUTHORIZATION
06/05/2017 ULORIC febuxostat REMOVE UM: AUTHORIZATION
PA applies
06/09/2017 EPINEPHRINE epinephrine ADD TO FORMULARY Covered 06/09/2017 EPINEPHRINE epinephrine ADD UM: QUANTITY 2 / 30 days 06/14/2017 fentanyl fentanyl ADD UM: AUTHORIZATION PA applies 06/19/2017 allopurinol allopurinol CHANGE TIER Covered 06/19/2017 allopurinol allopurinol CHANGE UM: QUANTITY 3 / days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 247 UPDATED 10/2018
July, 2017
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2017 INVOKAMET,INV
OKAMET XR canagliflozin/metformin hcl REMOVE UM:
AUTHORIZATION
07/01/2017 INVOKAMET XR canagliflozin/metformin hcl ADD TO FORMULARY Covered 07/01/2017 INVOKAMET XR canagliflozin/metformin hcl ADD UM: QUANTITY 60 / 1 month 07/01/2017 INVOKAMET XR canagliflozin/metformin hcl ADD TO FORMULARY Covered 07/01/2017 INVOKAMET XR canagliflozin/metformin hcl ADD UM: QUANTITY 2 / 1 days 07/01/2017 INVOKAMET XR canagliflozin/metformin hcl ADD TO FORMULARY Covered 07/01/2017 INVOKAMET XR canagliflozin/metformin hcl ADD UM: QUANTITY 2 / 1 days 07/01/2017 INVOKAMET XR canagliflozin/metformin hcl ADD TO FORMULARY Covered 07/01/2017 INVOKAMET XR canagliflozin/metformin hcl ADD UM: QUANTITY 2 / 1 days 07/01/2017 INVOKANA canagliflozin REMOVE UM:
AUTHORIZATION
07/01/2017 OTEZLA apremilast ADD TO FORMULARY Covered 07/01/2017 OTEZLA apremilast ADD UM: QUANTITY 2 / 1 days 07/01/2017 OTEZLA apremilast ADD TO FORMULARY Covered 07/01/2017 OTEZLA apremilast ADD TO FORMULARY Covered 07/01/2017 OTEZLA apremilast ADD UM: QUANTITY 2 / 1 days 07/01/2017 OTEZLA apremilast ADD UM: QUANTITY 1 / lifetime 07/01/2017 LONSURF trifluridine/tipiracil hcl ADD TO FORMULARY Covered 07/01/2017 LONSURF trifluridine/tipiracil hcl ADD UM: AUTHORIZATION PA applies 07/01/2017 LONSURF trifluridine/tipiracil hcl ADD TO FORMULARY Covered 07/01/2017 LONSURF trifluridine/tipiracil hcl ADD UM: AUTHORIZATION PA applies 07/01/2017 adapalene adapalene CHANGE TIER Covered Not Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 248 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
07/01/2017 adapalene adapalene REMOVE UM: QUANTITY 1.5 / day
07/01/2017 DIFFERIN adapalene ADD TO FORMULARY Covered 07/01/2017 DIFFERIN adapalene CHANGE UM: QUANTITY 45 / 30 days 07/01/2017 DIFFERIN adapalene ADD UM: CUSTOM Only OTC
Covered 07/01/2017 BASAGLAR
KWIKPEN U-100 insulin glargine,human recombinant analog
ADD TO FORMULARY Covered
07/01/2017 epiflur,ludent fluoride,sodium fluoride,fluoride,r enaf,luride,ethed ent
sodium fluoride,fluoride (sodium)
ADD UM: QUANTITY 1 / 1 days
07/01/2017 fluoritab,sodium fluoride,epiflur,lud ent fluoride,fluoride,r enaf,luride,ethed ent,pharmaflur
fluoride (sodium),sodium fluoride
ADD UM: QUANTITY 1 / 1 days
07/01/2017 retin- a,avita,tretinoin
tretinoin REMOVE FROM FORMULARY
Non-Formulary
07/01/2017 retin- a,avita,tretinoin
tretinoin REMOVE UM: AGE 10 to 29 yrs old
07/01/2017 retin- a,avita,tretinoin
tretinoin REMOVE UM: QUANTITY 1.5 / day
07/01/2017 retin-a,tretinoin tretinoin REMOVE FROM FORMULARY
Non-Formulary
07/01/2017 retin-a,tretinoin tretinoin REMOVE UM: AGE
07/01/2017 retin-a,tretinoin tretinoin REMOVE UM: QUANTITY
07/01/2017 retin-a,tretinoin tretinoin REMOVE FROM FORMULARY
Non-Formulary
07/01/2017 retin-a,tretinoin tretinoin REMOVE UM: AGE
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 249 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
07/01/2017 retin-a,tretinoin tretinoin REMOVE UM: QUANTITY
07/01/2017 retin-a,tretinoin tretinoin REMOVE FROM FORMULARY
Non-Formulary
07/01/2017 retin-a,tretinoin tretinoin REMOVE UM: AGE
07/01/2017 retin-a,tretinoin tretinoin REMOVE UM: QUANTITY
07/01/2017 retin- a,avita,tretinoin
tretinoin REMOVE FROM FORMULARY
Non-Formulary
07/01/2017 retin- a,avita,tretinoin
tretinoin REMOVE UM: AGE
07/01/2017 retin- a,avita,tretinoin
tretinoin REMOVE UM: QUANTITY
07/01/2017 adapalene adapalene REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2017 adapalene adapalene REMOVE UM: QUANTITY 1.5 / day
07/01/2017 adapalene adapalene REMOVE FROM FORMULARY
Not Covered Non-Formulary
07/01/2017 omeprazole omeprazole REMOVE FROM FORMULARY
Non-Formulary
07/01/2017 omeprazole omeprazole ADD UM: CUSTOM Only CAPS Covered
07/01/2017 vitamin e,aquavit- e,aquasol e
vitamin e ADD UM: AGE Up to 12 yrs old
07/01/2017 quinapril- hydrochlorothiazi de
quinapril hcl/hydrochlorothiazide
ADD TO FORMULARY Covered
07/01/2017 quinapril- hydrochlorothiazi de
quinapril hcl/hydrochlorothiazide
ADD TO FORMULARY Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 250 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
07/01/2017 quinapril- hydrochlorothiazi de
quinapril hcl/hydrochlorothiazide
ADD TO FORMULARY Covered
07/01/2017 EPANED enalapril maleate ADD TO FORMULARY Covered 07/01/2017 EPANED enalapril maleate ADD UM: AGE Up to 12 yrs old 07/01/2017 rosuvastatin
calcium rosuvastatin calcium CHANGE TIER Covered
07/01/2017 rosuvastatin calcium
rosuvastatin calcium CHANGE TIER Covered
07/01/2017 rosuvastatin calcium
rosuvastatin calcium CHANGE TIER Covered
07/01/2017 rosuvastatin calcium
rosuvastatin calcium CHANGE TIER Covered
07/01/2017 MEPHYTON phytonadione,phytonadione (vit k1)
ADD TO FORMULARY Covered
07/01/2017 MEPHYTON phytonadione,phytonadione (vit k1)
CHANGE UM: QUANTITY 5 / Day 3 / 30 days
07/01/2017 MEPHYTON phytonadione,phytonadione (vit k1)
REMOVE UM: CUSTOM Covered for CSHCS Only
07/01/2017 niacin inositol niacin (inositol niacinate) ADD TO FORMULARY Covered 07/01/2017 niacin flush-
free,niacin flush free,niacin
niacin (inositol niacinate) ADD TO FORMULARY Covered
07/01/2017 niacinamide niacinamide ADD TO FORMULARY Covered 07/01/2017 niacin flush free niacin (inositol niacinate) ADD TO FORMULARY Covered 07/01/2017 niacin niacin (inositol niacinate) ADD TO FORMULARY Covered 07/01/2017 niacin niacin (inositol niacinate) REMOVE UM: CUSTOM Covered for
CSHCS Only
07/01/2017 niacinamide niacinamide ADD TO FORMULARY Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 251 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
07/01/2017 niacinamide niacinamide REMOVE UM: CUSTOM Covered for CSHCS Only
07/01/2017 niacinamide niacinamide ADD TO FORMULARY Covered 07/01/2017 niacinamide niacinamide REMOVE UM: CUSTOM Covered for
CSHCS Only
07/01/2017 niacin niacinamide ADD TO FORMULARY Covered 07/01/2017 niacin niacinamide REMOVE UM: CUSTOM Covered for
CSHCS Only
07/01/2017 niacin niacin ADD TO FORMULARY Covered 07/01/2017 niacin niacin REMOVE UM: CUSTOM
07/01/2017 niacin,niacin td niacin ADD TO FORMULARY Covered 07/01/2017 niacin niacin ADD TO FORMULARY Covered 07/01/2017 niacin niacin REMOVE UM: CUSTOM Covered for
CSHCS Only
07/01/2017 niacin niacin REMOVE FROM FORMULARY
Non-Formulary
07/01/2017 niacin niacin ADD TO FORMULARY Covered 07/01/2017 niacin niacin ADD TO FORMULARY Covered 07/01/2017 niacin niacin REMOVE UM: CUSTOM Covered for
CSHCS Only
07/01/2017 niacin niacin ADD TO FORMULARY Covered 07/01/2017 niacin niacin REMOVE UM: CUSTOM Covered for
CSHCS Only
07/01/2017 endur-acin niacin ADD TO FORMULARY Covered 07/01/2017 endur-acin niacin REMOVE UM: CUSTOM Covered for
CSHCS Only
07/01/2017 SLO-NIACIN niacin REMOVE UM: CUSTOM Covered for CSHCS Only
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 252 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
07/01/2017 slo-niacin niacin ADD TO FORMULARY Covered 07/01/2017 endur-acin niacin ADD TO FORMULARY Covered 07/01/2017 niacin niacin ADD TO FORMULARY Covered 07/01/2017 niacin niacin ADD TO FORMULARY Covered 07/01/2017 niacin niacin REMOVE UM: CUSTOM Covered for
CSHCS Only
07/01/2017 niacin niacin ADD TO FORMULARY Covered 07/01/2017 niacin niacin (inositol niacinate) ADD TO FORMULARY Covered 07/01/2017 fenofibric acid fenofibric acid CHANGE TIER Covered 07/01/2017 fenofibric acid fenofibric acid ADD UM: QUANTITY 1 / 1 days 07/01/2017 fenofibric acid fenofibric acid ADD UM: QUANTITY 1 / 1 days 07/01/2017 fenofibrate fenofibrate CHANGE TIER Covered 07/01/2017 fenofibrate fenofibrate ADD UM: QUANTITY 1 / 1 days 07/01/2017 fenofibrate fenofibrate,micronized ADD UM: QUANTITY 1 / 1 days 07/01/2017 valsartan-
hydrochlorothiazi de
valsartan/hydrochlorothiazid e
CHANGE TIER Covered
07/01/2017 valsartan- hydrochlorothiazi de
valsartan/hydrochlorothiazid e
ADD UM: QUANTITY 1 / 1 days
07/01/2017 valsartan- hydrochlorothiazi de
valsartan/hydrochlorothiazid e
CHANGE TIER Covered
07/01/2017 valsartan- hydrochlorothiazi de
valsartan/hydrochlorothiazid e
ADD UM: QUANTITY 1 / 1 days
07/01/2017 valsartan- hydrochlorothiazi de
valsartan/hydrochlorothiazid e
CHANGE TIER Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 253 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
07/01/2017 valsartan- hydrochlorothiazi de
valsartan/hydrochlorothiazid e
ADD UM: QUANTITY 1 / 1 days
07/01/2017 valsartan- hydrochlorothiazi de
valsartan/hydrochlorothiazid e
ADD UM: QUANTITY 1 / 1 days
07/01/2017 valsartan- hydrochlorothiazi de
valsartan/hydrochlorothiazid e
ADD UM: QUANTITY 1 / 1 days
07/01/2017 valsartan valsartan CHANGE TIER Covered 07/01/2017 valsartan valsartan ADD UM: QUANTITY 1 / 1 days 07/01/2017 valsartan valsartan CHANGE TIER Covered 07/01/2017 valsartan valsartan ADD UM: QUANTITY 2 / 1 days 07/01/2017 valsartan valsartan CHANGE TIER Covered 07/01/2017 valsartan valsartan ADD UM: QUANTITY 2 / 1 days 07/01/2017 valsartan valsartan CHANGE TIER Covered 07/01/2017 valsartan valsartan ADD UM: QUANTITY 2 / 1 days 07/01/2017 cholestyramine cholestyramine (with sugar) ADD UM: QUANTITY 60 / 30 days 07/01/2017 cholestyramine
light cholestyramine/aspartame ADD UM: QUANTITY 60 / 30 days
07/01/2017 prevalite cholestyramine/aspartame ADD UM: QUANTITY 60 / 30 days 07/01/2017 hydrochlorothiazi
de,microzide hydrochlorothiazide REMOVE UM: QUANTITY
07/01/2017 hydrochlorothiazi de
hydrochlorothiazide REMOVE UM: QUANTITY
07/01/2017 hydrochlorothiazi de
hydrochlorothiazide REMOVE UM: QUANTITY
07/01/2017 fluvastatin sodium
fluvastatin sodium REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 254 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
07/01/2017 fluvastatin sodium
fluvastatin sodium REMOVE UM: QUANTITY 2 / days
07/01/2017 fluvastatin sodium
fluvastatin sodium REMOVE UM: QUANTITY 1 / Day
07/01/2017 lescol,fluvastatin sodium
fluvastatin sodium REMOVE UM: QUANTITY 2 / days
07/01/2017 lescol,fluvastatin sodium
fluvastatin sodium REMOVE FROM FORMULARY
Non-Formulary
07/01/2017 lescol,fluvastatin sodium
fluvastatin sodium REMOVE UM: QUANTITY
07/01/2017 fluvastatin sodium
fluvastatin sodium REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2017 klor- con,epiklor,potas sium chloride,kay ciel
potassium chloride REMOVE FROM FORMULARY
Non-Formulary
07/01/2017 potassium chloride,k-sol
potassium chloride REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2017 potassium chloride,kay ciel,k-sol
potassium chloride REMOVE FROM FORMULARY
Non-Formulary
07/01/2017 alphagan p,brimonidine tartrate
brimonidine tartrate REMOVE FROM FORMULARY
Non-Formulary
07/01/2017 alphagan p,brimonidine tartrate
brimonidine tartrate REMOVE UM: QUANTITY
07/01/2017 VIGAMOX moxifloxacin hcl REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2017 VIGAMOX moxifloxacin hcl REMOVE UM: QUANTITY 0.1 / day
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 255 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
07/01/2017 OB COMPLETE prenatal vitamins no.123/iron,carbonyl/folic acid
REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2017 vp-zel niacinamide/azelaic acid/zinc oxide/vit b6/copper/fa
REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2017 diabetic support formula
multivit with minerals/folic acid/lycopene/lutein/herbal 185
REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2017 one daily multivit,calcium,iron,mins/foli c acid/guarana seed/caffeine
REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2017 one daily multivit,calcium,iron,mins/foli c acid/guarana seed/caffeine
REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2017 hair, skin and nails
multivit with minerals/ferrous fum/folic acid/herbal no.186
REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2017 MEGAVITE multivitamin- minerals/iron/folic acid/herbal complex no.190
REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2017 VITAMIN D3 COMPLETE
multivitamin- minerals/iron/folic acid/herbal complex no.190
REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2017 timolol maleate timolol maleate REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2017 timolol maleate timolol maleate REMOVE UM: QUANTITY 10 / 30 days
07/01/2017 timolol maleate timolol maleate REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2017 timolol maleate timolol maleate REMOVE UM: QUANTITY 10 / 30 days
07/01/2017 FLAREX fluorometholone acetate REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 256 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
07/01/2017 PRED MILD prednisolone acetate REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2017 PRED MILD prednisolone acetate REMOVE UM: QUANTITY 10 / 30 days
07/01/2017 FML S.O.P. fluorometholone REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2017 FML FORTE fluorometholone REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2017 FML FORTE fluorometholone REMOVE UM: QUANTITY 10 / 30 days
07/01/2017 MEGAVITE GOLDEN YEARS 55+
multivit-min/folic ac/herbals 190,215/digestive enzymes no.4
REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2017 niacin-aze ac- turmer-fa-b6-zn
niacinamide/azelaic ac/quercet/turmer/fa/b6/zinc ox/copper
REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2017 NICADAN niacinamide/b6/c/folic acid/copper/mag/zinc/alpha lipoic acd
REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2017 blephamide s.o.p. sulfacetamide sodium/prednisolone acetate
REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2017 BLEPHAMIDE sulfacetamide sodium/prednisolone acetate
REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2017 TOBRADEX tobramycin/dexamethasone REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2017 travoprost travoprost (benzalkonium) REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2017 travoprost travoprost (benzalkonium) REMOVE UM: QUANTITY 5 / 30 days
07/01/2017 colestipol hcl colestipol hcl REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 257 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
07/01/2017 fenofibrate fenofibrate REMOVE FROM FORMULARY
Non-Formulary
07/01/2017 fenofibrate fenofibrate,micronized REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2017 niaspan,niacin er niacin REMOVE FROM FORMULARY
Non-Formulary
07/01/2017 niaspan,niacin er niacin REMOVE UM: QUANTITY 4 / days
07/01/2017 niaspan,niacin er niacin REMOVE FROM FORMULARY
Non-Formulary
07/01/2017 niaspan,niacin er niacin REMOVE UM: QUANTITY
07/01/2017 niacin er niacin REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2017 niacin er niacin REMOVE UM: QUANTITY 2 / Day
07/01/2017 AQUADEKS multivitamin, minerals no.51/folic acid/vit k1/ubidecarenone
ADD UM: CUSTOM CSHCS ONLY
07/01/2017 nicotine patch nicotine REMOVE UM: QUANTITY 1 / days
07/01/2017 niacin niacin REMOVE UM: CUSTOM Covered for CSHCS Only
07/01/2017 OTEZLA apremilast CHANGE UM: QUANTITY 2 / 1 days 1 / lifetime 07/01/2017 adapalene,differi
n adapalene ADD TO FORMULARY Not Covered
07/01/2017 adapalene,differi n
adapalene REMOVE UM: CUSTOM
07/01/2017 adapalene,differi n
adapalene REMOVE UM: QUANTITY 45 / 30 days
07/01/2017 DIFFERIN adapalene REMOVE FROM FORMULARY
Not Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 258 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
07/01/2017 adapalene adapalene REMOVE FROM FORMULARY
Not Covered Non-Formulary
07/01/2017 nicotine lozenge nicotine polacrilex CHANGE TIER Covered 07/01/2017 nicotine lozenge nicotine polacrilex CHANGE UM: QUANTITY 20 / 1 days 07/01/2017 DIFFERIN adapalene ADD TO FORMULARY Non-Formulary Covered 07/01/2017 DIFFERIN adapalene ADD UM: QUANTITY 45 / 30 days 07/01/2017 DIFFERIN adapalene ADD UM: CUSTOM ONLY OTC
Covered 07/01/2017 ELIQUIS apixaban ADD TO FORMULARY Covered 07/01/2017 ELIQUIS apixaban ADD UM: QUANTITY 2 / 1 days 07/01/2017 ELIQUIS apixaban ADD TO FORMULARY Covered 07/01/2017 ELIQUIS apixaban ADD UM: QUANTITY 2 / 1 days 07/07/2017 ZENPEP lipase/protease/amylase ADD TO FORMULARY Non-Formulary Covered 07/07/2017 ZENPEP lipase/protease/amylase ADD UM: QUANTITY 720 / 30 days 07/15/2017 imiquimod imiquimod CHANGE UM: QUANTITY 0.4 / day 0.43 / 1 days 07/15/2017 imiquimod imiquimod REMOVE UM:
AUTHORIZATION PA applies
07/18/2017 cyproheptadine hcl
cyproheptadine hcl CHANGE TIER Covered
07/18/2017 cyproheptadine hcl
cyproheptadine hcl CHANGE UM: AGE Up to 64 yrs old
07/18/2017 vancomycin hcl vancomycin hcl CHANGE TIER Covered 07/18/2017 fish oil,fish oil
omega-3 omega-3 fatty acids/fish oil,omega-3 fatty acids/dha/epa/other omega- 3s/fish oil
CHANGE TIER Covered
07/18/2017 acetazolamide acetazolamide CHANGE TIER Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 259 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
07/18/2017 hydrocodone- acetaminophen
hydrocodone bitartrate/acetaminophen
CHANGE TIER Covered
07/18/2017 hydrocodone- acetaminophen
hydrocodone bitartrate/acetaminophen
CHANGE UM: QUANTITY 180 / days
07/18/2017 hydrocodone- acetaminophen
hydrocodone bitartrate/acetaminophen
CHANGE UM: CUSTOM Cumulative APAP 4gm/day & MED 200mg/day
Edits 07/18/2017 prenatal
vitamins,prenatal prenatal vitamins with calcium/ferrous fumarate/folic acid,prenatal vit with calcium no.130/ferrous fumarate/folic acid,prenatal vitamins/ferrous fumarate/folic acid
CHANGE TIER Covered
07/18/2017 prenatal vitamins,prenatal
prenatal vitamins with calcium/ferrous fumarate/folic acid,prenatal vit with calcium no.130/ferrous fumarate/folic acid,prenatal vitamins/ferrous fumarate/folic acid
CHANGE UM: AGE 12 to 55 yrs old
07/18/2017 prenatal vitamins,prenatal
prenatal vitamins with calcium/ferrous fumarate/folic acid,prenatal vit with calcium no.130/ferrous fumarate/folic acid,prenatal vitamins/ferrous fumarate/folic acid
CHANGE UM: GENDER Female
07/18/2017 nicotine lozenge nicotine polacrilex ADD TO FORMULARY Covered 07/18/2017 nicotine lozenge nicotine polacrilex CHANGE UM: QUANTITY 20 / days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 260 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
07/18/2017 vitamin e vitamin e,vitamin e acetate CHANGE TIER Covered 07/18/2017 HYCAMTIN topotecan hcl CHANGE TIER Covered 07/18/2017 HYCAMTIN topotecan hcl CHANGE UM:
AUTHORIZATION PA applies
07/18/2017 TEKTURNA aliskiren hemifumarate CHANGE TIER Covered 07/18/2017 TEKTURNA aliskiren hemifumarate CHANGE UM: QUANTITY 1 / days 07/18/2017 TEKTURNA aliskiren hemifumarate CHANGE TIER Covered 07/18/2017 TEKTURNA aliskiren hemifumarate CHANGE UM: QUANTITY 1 / days 07/18/2017 TEKTURNA HCT aliskiren
hemifumarate/hydrochlorothi azide
CHANGE TIER Covered
07/18/2017 TEKTURNA HCT aliskiren hemifumarate/hydrochlorothi azide
CHANGE UM: QUANTITY 1 / days
07/18/2017 women's 50+ daily formula,women's 50 plus daily formula
multivit with minerals/folic acid/calcium carbonate/vit k1
CHANGE TIER Covered
07/18/2017 motion-time meclizine hcl CHANGE TIER Covered 07/19/2017 castor oil castor oil REMOVE FROM
FORMULARY Covered Non-Formulary
07/19/2017 PRESERVISION AREDS 2
vit c/vit e acetate/zinc oxid/cupric oxide/lutein/zeaxanthin
CHANGE TIER Not Covered
07/19/2017 vitamin d3 cholecalciferol (vitamin d3) REMOVE UM: CUSTOM
07/19/2017 central-vite select multivitamin with minerals/lutein,multivitamin with iron and other minerals
REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 261 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
07/19/2017 foltabs 800 cyanocobalamin/folic acid/pyridoxine
CHANGE TIER Covered
07/19/2017 alendronate sodium
alendronate sodium CHANGE TIER Covered
07/19/2017 alendronate sodium
alendronate sodium CHANGE UM: QUANTITY 1 / days
07/19/2017 PRESERVISION AREDS 2
vit c/vit e acetate/zinc oxid/cupric oxide/lutein/zeaxanthin
REMOVE FROM FORMULARY
Not Covered Non-Formulary
07/20/2017 SPINRAZA nusinersen sodium/pf ADD TO FORMULARY Not Covered 07/20/2017 SPINRAZA nusinersen sodium/pf ADD UM: CUSTOM Contact MDHHS
Program Review Division at 800-
622-0276 07/20/2017 SPINRAZA nusinersen sodium/pf ADD UM: MED Medical Drug 07/31/2017 prevident,phos-
flur,sf,fluoridex daily defense,fluoridex defense whitening,dentag el,thera-flur- n,neutragard advanced,cavare st,neutragard,eth edent
fluoride (sodium),sodium fluoride
REMOVE UM: AGE Up to 16 yrs old
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 262 UPDATED 10/2018
August, 2017
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/01/2017 sulfatrim sulfamethoxazole/trimethopr
im ADD TO FORMULARY Non-Formulary Covered
08/01/2017 VOSEVI sofosbuvir/velpatasvir/voxila previr
ADD TO FORMULARY Not Covered
08/01/2017 VOSEVI sofosbuvir/velpatasvir/voxila previr
ADD UM: CUSTOM Carve-Out Drug, Bill Medicaid FFS08/02/2017 VOSEVI sofosbuvir/velpatasvir/voxila
previr REMOVE FROM
FORMULARY Not Covered Non-Formulary
08/14/2017 FLUBLOK QUAD 2017-2018
influenza virus vaccine qv 2017-18(18 yrs and older)rcmb/pf
ADD TO FORMULARY Covered
08/14/2017 FLUBLOK QUAD 2017-2018
influenza virus vaccine qv 2017-18(18 yrs and older)rcmb/pf
ADD UM: QUANTITY 1 / 270 days
08/14/2017 FLUZONE QUAD 2017-2018
influenza virus vaccine quadrivalent 2017-18 (36 mos up)/pf
ADD TO FORMULARY Covered
08/14/2017 FLUZONE QUAD 2017-2018
influenza virus vaccine quadrivalent 2017-18 (36 mos up)/pf
ADD UM: QUANTITY 1 / 270 days
08/14/2017 FLUZONE QUAD 2017-2018
influenza virus vaccine quadrivalent 2017-18 (36 mos up)/pf
ADD TO FORMULARY Covered
08/14/2017 FLUZONE QUAD 2017-2018
influenza virus vaccine quadrivalent 2017-18 (36 mos up)/pf
ADD UM: QUANTITY 1 / 270 days
08/14/2017 FLUZONE HIGH- DOSE 2017-2018
influenza virus vaccine trival split 2017-2018(65 yr up)/pf
ADD TO FORMULARY Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 263 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
08/14/2017 FLUZONE HIGH- DOSE 2017-2018
influenza virus vaccine trival split 2017-2018(65 yr up)/pf
ADD UM: QUANTITY 1 / 270 days
08/14/2017 FLUBLOK 2017- 2018
influenza virus vaccine tv 2017-18(18 yrs and older)rcmb/pf
ADD TO FORMULARY Covered
08/14/2017 FLUBLOK 2017- 2018
influenza virus vaccine tv 2017-18(18 yrs and older)rcmb/pf
ADD UM: QUANTITY 1 / 270 days
08/14/2017 FLUZONE QUAD 2017-2018
influenza virus vaccine quadrivalent 2017-18 (6 mos and up)
ADD TO FORMULARY Covered
08/14/2017 FLUZONE QUAD 2017-2018
influenza virus vaccine quadrivalent 2017-18 (6 mos and up)
ADD UM: QUANTITY 1 / 270 days
08/14/2017 FLUZONE QUAD PEDI 2017-2018
influenza virus vaccine quadrival 2017-18 (6 mos- 35 mos)/pf
ADD TO FORMULARY Covered
08/14/2017 FLUZONE QUAD PEDI 2017-2018
influenza virus vaccine quadrival 2017-18 (6 mos- 35 mos)/pf
ADD UM: QUANTITY 1 / 270 days
08/14/2017 FLUZONE INTRADERM QUAD 2017-18
influenza virus vaccine quadrivalent 2017-18(18yrs- 64yrs)/pf
ADD TO FORMULARY Covered
08/14/2017 FLUZONE INTRADERM QUAD 2017-18
influenza virus vaccine quadrivalent 2017-18(18yrs- 64yrs)/pf
ADD UM: QUANTITY 1 / 270 days
08/14/2017 FLUVIRIN 2017- 2018
influenza virus vaccine trival 2017-2018 (4yr and older)/pf
ADD TO FORMULARY Covered
08/14/2017 FLUVIRIN 2017- 2018
influenza virus vaccine trival 2017-2018 (4yr and older)/pf
ADD UM: QUANTITY 1 / 270 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 264 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
08/14/2017 FLUVIRIN 2017- 2018
influenza virus vaccine trivalent 2017-2018 (4 yr and older)
ADD TO FORMULARY Covered
08/14/2017 FLUVIRIN 2017- 2018
influenza virus vaccine trivalent 2017-2018 (4 yr and older)
ADD UM: QUANTITY 1 / 270 days
08/14/2017 FLUAD 2017- 2018
influenza vaccine tvs 2017- 18 (65 yr up)/adjuvant mf59c.1/pf
ADD TO FORMULARY Covered
08/14/2017 FLUAD 2017- 2018
influenza vaccine tvs 2017- 18 (65 yr up)/adjuvant mf59c.1/pf
ADD UM: QUANTITY 1 / 270 days
08/14/2017 FLUCELVAX QUAD 2017- 2018
flu vaccine quad 2017- 2018(4 years and older)cell derived/pf
ADD TO FORMULARY Covered
08/14/2017 FLUCELVAX QUAD 2017- 2018
flu vaccine quad 2017- 2018(4 years and older)cell derived/pf
ADD UM: QUANTITY 1 / 270 days
08/14/2017 FLUCELVAX QUAD 2017- 2018
flu vaccine quadriv 2017- 2018(4 years and older)cell derived
ADD TO FORMULARY Covered
08/14/2017 FLUCELVAX QUAD 2017- 2018
flu vaccine quadriv 2017- 2018(4 years and older)cell derived
ADD UM: QUANTITY 1 / 270 days
08/21/2017 FLUARIX QUAD 2017-2018
influenza virus vaccine qvalsplit 2017-2018(6 mos and up)/pf
ADD TO FORMULARY Covered
08/21/2017 FLULAVAL QUAD 2017- 2018
influenza virus vaccine quadrivalent 2017-18 (6 mos and up)
ADD TO FORMULARY Covered
08/21/2017 AFLURIA QUAD 2017-2018
influenza virus vaccine quadrivalent 2017-18 (5 year and up)
ADD TO FORMULARY Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 265 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
08/21/2017 AFLURIA QUAD 2017-2018
influenza virus vaccine quadrivalent 2017-18(5 yr and up)/pf
ADD TO FORMULARY Covered
08/21/2017 FLULAVAL QUAD 2017- 2018
influenza virus vaccine qvalsplit 2017-2018(6 mos and up)/pf
ADD TO FORMULARY Covered
08/21/2017 FLULAVAL QUAD 2017- 2018
influenza virus vaccine qvalsplit 2017-2018(6 mos and up)/pf
ADD UM: QUANTITY 1 / 270 days
08/21/2017 FLUZONE QUAD 2017- 2018,FLUARIX QUAD 2017- 2018
influenza virus vaccine quadrivalent 2017-18 (36 mos up)/pf,influenza virus vaccine qvalsplit 2017- 2018(6 mos and up)/pf
CHANGE UM: QUANTITY 1 / 270 days
08/21/2017 FLUZONE QUAD 2017- 2018,FLULAVAL QUAD 2017- 2018
influenza virus vaccine quadrivalent 2017-18 (6 mos and up)
CHANGE UM: QUANTITY 1 / 270 days
08/21/2017 AFLURIA QUAD 2017-2018
influenza virus vaccine quadrivalent 2017-18 (5 year and up)
ADD UM: QUANTITY 1 / 270 days
08/21/2017 AFLURIA QUAD 2017-2018
influenza virus vaccine quadrivalent 2017-18(5 yr and up)/pf
ADD UM: QUANTITY 1 / 270 days
08/21/2017 AFLURIA 2017- 2018
influenza virus vaccine trivalent 2017-2018 (5 years up)/pf
ADD TO FORMULARY Covered
08/21/2017 AFLURIA 2017- 2018
influenza virus vaccine trivalent 2017-2018 (5 years up)/pf
ADD UM: QUANTITY 1 / 270 days
08/21/2017 AFLURIA 2017- 2018
influenza virus vaccine trivalent 2017-2018 (5 yr and older)
ADD TO FORMULARY Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 266 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
08/21/2017 AFLURIA 2017- 2018
influenza virus vaccine trivalent 2017-2018 (5 yr and older)
ADD UM: QUANTITY 1 / 270 days
08/21/2017 auvi- q,epinephrine,epi pen,epipen 2- pak,adrenaclick
epinephrine CHANGE UM: QUANTITY 2 / 30 days
08/21/2017 auvi- q,adrenaclick,epi nephrine
epinephrine CHANGE UM: QUANTITY 2 / 30 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 267 UPDATED 10/2018
September, 2017
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/15/2017 lanthanum
carbonate lanthanum carbonate ADD TO FORMULARY Covered
09/15/2017 lanthanum carbonate
lanthanum carbonate ADD TO FORMULARY Covered
09/15/2017 lanthanum carbonate
lanthanum carbonate ADD TO FORMULARY Covered
09/15/2017 FOSRENOL lanthanum carbonate REMOVE FROM FORMULARY
Covered Non-Formulary
09/15/2017 FOSRENOL lanthanum carbonate REMOVE FROM FORMULARY
Covered Non-Formulary
09/15/2017 FOSRENOL lanthanum carbonate REMOVE FROM FORMULARY
Covered Non-Formulary
09/15/2017 VIVITROL naltrexone microspheres ADD TO FORMULARY Not Covered 09/15/2017 VIVITROL naltrexone microspheres ADD UM: CUSTOM MDHHS Carve-
Out Drug, Bill FFS
09/15/2017 VIVITROL naltrexone microspheres ADD TO FORMULARY Not Covered 09/15/2017 VIVITROL naltrexone microspheres ADD UM: CUSTOM MDHHS Carve-
Out, Bill MDHHS FFS
09/16/2017 VIVITROL naltrexone microspheres REMOVE FROM FORMULARY
Not Covered Non-Formulary
09/30/2017 LANTUS insulin glargine,human recombinant analog,insulin glargine, human recombinant analog
REMOVE FROM FORMULARY
Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 268 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
09/30/2017 LANTUS insulin glargine,human recombinant analog,insulin glargine, human recombinant analog
REMOVE UM: QUANTITY
09/30/2017 LANTUS SOLOSTAR,BAS AGLAR KWIKPEN U-100
insulin glargine,human recombinant analog,insulin glargine, human recombinant analog
REMOVE FROM FORMULARY
Non-Formulary
09/30/2017 LANTUS SOLOSTAR,BAS AGLAR KWIKPEN U-100
insulin glargine,human recombinant analog,insulin glargine, human recombinant analog
REMOVE UM: QUANTITY
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 269 UPDATED 10/2018
October, 2017
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2017 midazolam hcl midazolam hcl ADD TO FORMULARY Covered 10/01/2017 midazolam hcl midazolam hcl ADD UM: QUANTITY 4 / 30 days 10/01/2017 midazolam hcl midazolam hcl/pf ADD TO FORMULARY Covered 10/01/2017 midazolam hcl midazolam hcl/pf ADD UM: QUANTITY 4 / 30 days 10/01/2017 LO LOESTRIN
FE norethindrone acetate- ethinyl estradiol/ferrous fumarate
REMOVE FROM FORMULARY
Covered Non-Formulary
10/01/2017 SAFYRAL drospirenone/ethinyl estradiol/levomefolate calcium
REMOVE FROM FORMULARY
Covered Non-Formulary
10/01/2017 zarah ethinyl estradiol/drospirenone
CHANGE TIER Covered
10/01/2017 YASMIN 28 ethinyl estradiol/drospirenone
REMOVE UM: GENDER Female
10/01/2017 balziva norethindrone-ethinyl estradiol
CHANGE TIER Covered
10/01/2017 zenchent norethindrone-ethinyl estradiol
CHANGE TIER Covered
10/01/2017 nortrel norethindrone-ethinyl estradiol
CHANGE TIER Covered
10/01/2017 necon norethindrone-ethinyl estradiol
CHANGE TIER Covered
10/01/2017 nortrel norethindrone-ethinyl estradiol
CHANGE TIER Covered
10/01/2017 microgestin norethindrone acetate- ethinyl estradiol
CHANGE TIER Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 270 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
10/01/2017 norethindron- ethinyl estradiol
norethindrone acetate- ethinyl estradiol
CHANGE TIER Covered
10/01/2017 zeosa norethindrone-ethinyl estradiol/ferrous fumarate
REMOVE UM: AUTHORIZATION
PA applies
10/01/2017 wymzya fe norethindrone-ethinyl estradiol/ferrous fumarate
REMOVE UM: AUTHORIZATION
10/01/2017 FEMCON FE norethindrone-ethinyl estradiol/ferrous fumarate
REMOVE UM: GENDER Female
10/01/2017 FEMCON FE norethindrone-ethinyl estradiol/ferrous fumarate
REMOVE UM: AUTHORIZATION
PA applies
10/01/2017 LAYOLIS FE norethindrone-ethinyl estradiol/ferrous fumarate
REMOVE FROM FORMULARY
Covered Non-Formulary
10/01/2017 LAYOLIS FE norethindrone-ethinyl estradiol/ferrous fumarate
REMOVE UM: GENDER Female
10/01/2017 LAYOLIS FE norethindrone-ethinyl estradiol/ferrous fumarate
REMOVE UM: AUTHORIZATION
PA applies
10/01/2017 GENERESS FE norethindrone-ethinyl estradiol/ferrous fumarate
REMOVE UM: GENDER Female
10/01/2017 GENERESS FE norethindrone-ethinyl estradiol/ferrous fumarate
REMOVE UM: AUTHORIZATION
PA applies
10/01/2017 ORTHO TRI- CYCLEN
norgestimate-ethinyl estradiol
REMOVE FROM FORMULARY
Covered Non-Formulary
10/01/2017 ORTHO TRI- CYCLEN
norgestimate-ethinyl estradiol
REMOVE UM: GENDER Female
10/01/2017 ORTHO TRI- CYCLEN
norgestimate-ethinyl estradiol
REMOVE UM: QUANTITY 84 / 84 days
10/01/2017 yuvafem estradiol ADD TO FORMULARY Covered 10/01/2017 tolnaftate tolnaftate ADD TO FORMULARY Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 271 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
10/01/2017 athlete's foot cream,athlete's foot
tolnaftate ADD TO FORMULARY Covered
10/01/2017 antifungal cream tolnaftate ADD TO FORMULARY Covered 10/01/2017 fungoid-d tolnaftate ADD TO FORMULARY Covered 10/01/2017 podactin tolnaftate ADD TO FORMULARY Covered 10/01/2017 tolnaftate tolnaftate ADD TO FORMULARY Covered 10/01/2017 anti-fungal tolnaftate ADD TO FORMULARY Covered 10/01/2017 fluticasone
propionate fluticasone propionate CHANGE TIER Covered
10/01/2017 allergy relief fluticasone propionate ADD TO FORMULARY Covered 10/01/2017 aller-flo fluticasone propionate ADD TO FORMULARY Covered 10/01/2017 clarispray fluticasone propionate ADD TO FORMULARY Covered 10/01/2017 allergy chlorpheniramine maleate CHANGE TIER Covered 10/01/2017 CHLOR-
TRIMETON chlorpheniramine maleate REMOVE FROM
FORMULARY Covered Non-Formulary
10/01/2017 BETHKIS tobramycin ADD TO FORMULARY Covered 10/01/2017 fluticasone-
salmeterol fluticasone propionate/salmeterol xinafoate
ADD TO FORMULARY Covered
10/01/2017 fluticasone- salmeterol
fluticasone propionate/salmeterol xinafoate
ADD UM: QUANTITY 1 / 30 days
10/01/2017 fluticasone- salmeterol
fluticasone propionate/salmeterol xinafoate
ADD TO FORMULARY Covered
10/01/2017 fluticasone- salmeterol
fluticasone propionate/salmeterol xinafoate
ADD UM: QUANTITY 1 / 30 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 272 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
10/01/2017 fluticasone- salmeterol
fluticasone propionate/salmeterol xinafoate
ADD TO FORMULARY Covered
10/01/2017 fluticasone- salmeterol
fluticasone propionate/salmeterol xinafoate
ADD UM: QUANTITY 1 / 30 days
10/01/2017 MINASTRIN 24 FE
norethindrone acetate- ethinyl estradiol/ferrous fumarate
REMOVE FROM FORMULARY
Covered Non-Formulary
10/01/2017 MINASTRIN 24 FE
norethindrone acetate- ethinyl estradiol/ferrous fumarate
REMOVE UM: GENDER Female
10/01/2017 MINASTRIN 24 FE
norethindrone acetate- ethinyl estradiol/ferrous fumarate
REMOVE UM: AUTHORIZATION
PA applies
10/01/2017 norethin-eth estra-ferrous fum
norethindrone acetate- ethinyl estradiol/ferrous fumarate
ADD TO FORMULARY Covered
10/01/2017 norethin-eth estra-ferrous fum
norethindrone acetate- ethinyl estradiol/ferrous fumarate
ADD UM: GENDER Female
10/01/2017 mibelas 24 fe norethindrone acetate- ethinyl estradiol/ferrous fumarate
ADD TO FORMULARY Covered
10/01/2017 mibelas 24 fe norethindrone acetate- ethinyl estradiol/ferrous fumarate
ADD UM: GENDER Female
10/01/2017 ORTHO TRI- CYCLEN LO
norgestimate-ethinyl estradiol
REMOVE UM: GENDER Female
10/01/2017 ORTHO TRI- CYCLEN LO
norgestimate-ethinyl estradiol
REMOVE UM: QUANTITY 28 / 28 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 273 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
10/01/2017 INCRUSE ELLIPTA
umeclidinium bromide ADD UM: QUANTITY 30 / 30 days
10/01/2017 fondaparinux sodium
fondaparinux sodium REMOVE FROM FORMULARY
Non-Formulary
10/01/2017 arixtra,fondaparin ux sodium
fondaparinux sodium REMOVE UM: AUTHORIZATION
10/01/2017 arixtra,fondaparin ux sodium
fondaparinux sodium REMOVE FROM FORMULARY
Non-Formulary
10/01/2017 arixtra,fondaparin ux sodium
fondaparinux sodium REMOVE UM: AUTHORIZATION
10/01/2017 arixtra,fondaparin ux sodium
fondaparinux sodium REMOVE UM: AUTHORIZATION
10/01/2017 arixtra,fondaparin ux sodium
fondaparinux sodium REMOVE FROM FORMULARY
Non-Formulary
10/01/2017 arixtra,fondaparin ux sodium
fondaparinux sodium REMOVE UM: AUTHORIZATION
10/01/2017 PREMARIN estrogens, conjugated REMOVE UM: GENDER Female
10/01/2017 PREMARIN estrogens, conjugated REMOVE UM: QUANTITY 1.5 / day
10/01/2017 TUDORZA PRESSAIR
aclidinium bromide REMOVE FROM FORMULARY
Covered Non-Formulary
10/01/2017 TUDORZA PRESSAIR
aclidinium bromide REMOVE UM: QUANTITY 1 / 30 days
10/01/2017 SPIRIVA tiotropium bromide REMOVE FROM FORMULARY
Covered Non-Formulary
10/01/2017 SPIRIVA tiotropium bromide REMOVE UM: QUANTITY 1 / Day
10/01/2017 SPIRIVA RESPIMAT
tiotropium bromide REMOVE FROM FORMULARY
Covered Non-Formulary
10/01/2017 SPIRIVA RESPIMAT
tiotropium bromide REMOVE UM: QUANTITY 4 / 30 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 274 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
10/01/2017 SPIRIVA RESPIMAT
tiotropium bromide REMOVE FROM FORMULARY
Covered Non-Formulary
10/01/2017 SPIRIVA RESPIMAT
tiotropium bromide REMOVE UM: QUANTITY 4 / 30 days
10/01/2017 EMFLAZA deflazacort REMOVE FROM FORMULARY
Non-Formulary
10/01/2017 EUCRISA crisaborole REMOVE FROM FORMULARY
Non-Formulary
10/01/2017 IMPAVIDO miltefosine REMOVE FROM FORMULARY
Non-Formulary
10/01/2017 RAYALDEE calcifediol REMOVE FROM FORMULARY
Non-Formulary
10/01/2017 XERMELO telotristat etiprate REMOVE FROM FORMULARY
Non-Formulary
10/01/2017 ADLYXIN lixisenatide REMOVE FROM FORMULARY
Non-Formulary
10/01/2017 ADLYXIN lixisenatide REMOVE FROM FORMULARY
Non-Formulary
10/01/2017 SOLIQUA 100-33 insulin glargine,human recombinant analog/lixisenatide
REMOVE FROM FORMULARY
Non-Formulary
10/01/2017 XULTOPHY 100- 3.6
insulin degludec/liraglutide REMOVE FROM FORMULARY
Non-Formulary
10/01/2017 BASAGLAR KWIKPEN U-100
insulin glargine,human recombinant analog
ADD TO FORMULARY Non-Formulary Covered
10/01/2017 BASAGLAR KWIKPEN U-100
insulin glargine,human recombinant analog
ADD UM: QUANTITY 30 / 30 days
10/01/2017 arixtra,fondaparin ux sodium
fondaparinux sodium REMOVE FROM FORMULARY
Non-Formulary
10/01/2017 PREMARIN estrogens, conjugated REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 275 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
10/01/2017 ORTHO TRI- CYCLEN LO
norgestimate-ethinyl estradiol
REMOVE FROM FORMULARY
Covered Non-Formulary
10/08/2017 augmentin,amoxi cillin-clavulanate potass,amox tr- potassium clavulanate
amoxicillin/potassium clavulanate
ADD UM: AGE Up to 12 yrs old
10/08/2017 augmentin es- 600,amoxicillin- clavulanate potass,amox tr- potassium clavulanate
amoxicillin/potassium clavulanate
ADD UM: AGE Up to 12 yrs old
10/08/2017 amoxicillin- clavulanate potass,amox tr- potassium clavulanate
amoxicillin/potassium clavulanate
CHANGE TIER Covered
10/11/2017 LEVEMIR insulin detemir CHANGE UM: QUANTITY 2 / Day 2 / days 10/11/2017 LEVEMIR insulin detemir ADD UM: AGE 0 to 6 yrs old 10/11/2017 LEVEMIR
FLEXPEN insulin detemir CHANGE UM: QUANTITY 0.667 / day 2 / days
10/11/2017 LEVEMIR FLEXPEN
insulin detemir ADD UM: AGE 0 to 6 yrs old
10/11/2017 LEVEMIR FLEXTOUCH
insulin detemir CHANGE UM: QUANTITY 0.667 / day 2 / days
10/11/2017 LEVEMIR FLEXTOUCH
insulin detemir ADD UM: AGE 0 to 6 yrs old
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 276 UPDATED 10/2018
November, 2017
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/01/2017 zetia,ezetimibe ezetimibe CHANGE UM: QUANTITY 1 / days 11/01/2017 zetia,ezetimibe ezetimibe ADD UM: AUTHORIZATION PA applies 11/01/2017 ezetimibe ezetimibe ADD TO FORMULARY Covered 11/01/2017 ZETIA ezetimibe REMOVE FROM
FORMULARY Covered Non-Formulary
11/07/2017 MAVYRET glecaprevir/pibrentasvir REMOVE FROM FORMULARY
Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 277 UPDATED 10/2018
December, 2017
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 12/01/2017 oseltamivir
phosphate oseltamivir phosphate ADD TO FORMULARY Covered
12/01/2017 oseltamivir phosphate
oseltamivir phosphate ADD UM: QUANTITY 120 / 180 days
12/01/2017 TAMIFLU oseltamivir phosphate CHANGE TIER Covered Not Covered 12/01/2017 TAMIFLU oseltamivir phosphate REMOVE UM: QUANTITY 60 / Rx
12/01/2017 oseltamivir phosphate
oseltamivir phosphate ADD UM: AGE Up to 12 yrs old
12/01/2017 oseltamivir phosphate
oseltamivir phosphate ADD UM: CUSTOM Max 120ml per 180 days
12/01/2017 ADEMPAS riociguat REMOVE UM: AUTHORIZATION
12/02/2017 TAMIFLU oseltamivir phosphate REMOVE FROM FORMULARY
Not Covered Non-Formulary
12/03/2017 tamiflu,oseltamivi r phosphate
oseltamivir phosphate CHANGE UM: QUANTITY 60 / 1 rx
12/12/2017 POLY-VI-SOL pediatric multivitamin no.81 REMOVE UM: CUSTOM Covered for CSHCS Only
12/19/2017 TRUVADA,DESC OVY
emtricitabine/tenofovir disoproxil fumarate,emtricitabine/tenof ovir alafenamide fumarate
CHANGE UM: CUSTOM Carve Out Drug- Bill MDCH FFS
12/20/2017 hycet,hydrocodon e-acetaminophen
hydrocodone bitartrate/acetaminophen
CHANGE UM: QUANTITY 480 / 30 days
12/21/2017 JULUCA dolutegravir sodium/rilpivirine hcl
ADD UM: CUSTOM Carveout Drug - Bill MDCH FFS
12/31/2017 FARXIGA dapagliflozin propanediol ADD UM: AUTHORIZATION PA applies
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 278 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
12/31/2017 FARXIGA dapagliflozin propanediol ADD UM: AUTHORIZATION PA applies
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 279 UPDATED 10/2018
January, 2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2018 testosterone testosterone ADD TO FORMULARY Covered 01/01/2018 testosterone testosterone ADD UM: GENDER Male 01/01/2018 testosterone testosterone ADD TO FORMULARY Covered 01/01/2018 testosterone testosterone ADD UM: GENDER Male 01/01/2018 testosterone testosterone REMOVE FROM
FORMULARY Covered Non-Formulary
01/01/2018 testosterone testosterone REMOVE FROM FORMULARY
Covered Non-Formulary
01/01/2018 testosterone testosterone REMOVE UM: GENDER Male
01/01/2018 testosterone testosterone REMOVE UM: GENDER Male
01/01/2018 JARDIANCE empagliflozin ADD TO FORMULARY Covered 01/01/2018 JARDIANCE empagliflozin ADD UM: QUANTITY 30 / 30 days 01/01/2018 JARDIANCE empagliflozin ADD TO FORMULARY Covered 01/01/2018 JARDIANCE empagliflozin ADD UM: QUANTITY 30 / 30 days 01/01/2018 ZENPEP lipase/protease/amylase ADD UM: QUANTITY 480 / 30 days 01/01/2018 FARXIGA dapagliflozin propanediol REMOVE FROM
FORMULARY Covered Non-Formulary
01/01/2018 FARXIGA dapagliflozin propanediol REMOVE UM: QUANTITY 1 / Day
01/01/2018 FARXIGA dapagliflozin propanediol REMOVE UM: QUANTITY 1 / Day
01/01/2018 wide seal diaphragm
diaphragms, wide seal ADD TO FORMULARY Covered
01/01/2018 wide seal diaphragm
diaphragms, wide seal ADD TO FORMULARY Covered
01/01/2018 wide seal diaphragm
diaphragms, wide seal ADD TO FORMULARY Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 280 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
01/01/2018 wide seal diaphragm
diaphragms, wide seal ADD TO FORMULARY Covered
01/01/2018 wide seal diaphragm
diaphragms, wide seal ADD TO FORMULARY Covered
01/01/2018 wide seal diaphragm
diaphragms, wide seal ADD TO FORMULARY Covered
01/01/2018 wide seal diaphragm
diaphragms, wide seal ADD TO FORMULARY Covered
01/01/2018 wide seal diaphragm
diaphragms, wide seal ADD TO FORMULARY Covered
01/01/2018 caya contoured diaphragms, contoured ADD TO FORMULARY Covered 01/01/2018 SYNJARDY empagliflozin/metformin hcl ADD TO FORMULARY Non-Formulary Covered 01/01/2018 SYNJARDY empagliflozin/metformin hcl ADD TO FORMULARY Non-Formulary Covered 01/01/2018 SYNJARDY empagliflozin/metformin hcl ADD TO FORMULARY Non-Formulary Covered 01/01/2018 SYNJARDY empagliflozin/metformin hcl ADD TO FORMULARY Non-Formulary Covered 01/01/2018 SYNJARDY,SYN
JARDY XR empagliflozin/metformin hcl ADD UM: QUANTITY 60 / 30 days
01/01/2018 SYNJARDY XR empagliflozin/metformin hcl ADD TO FORMULARY Covered 01/01/2018 SYNJARDY XR empagliflozin/metformin hcl ADD TO FORMULARY Covered 01/01/2018 SYNJARDY XR empagliflozin/metformin hcl ADD TO FORMULARY Covered 01/01/2018 SYNJARDY XR empagliflozin/metformin hcl ADD TO FORMULARY Covered 01/01/2018 SYNJARDY XR empagliflozin/metformin hcl ADD UM: QUANTITY 30 / 30 days 01/01/2018 SYNJARDY XR empagliflozin/metformin hcl ADD UM: QUANTITY 30 / 30 days 01/01/2018 HUMALOG
JUNIOR KWIKPEN
insulin lispro ADD TO FORMULARY Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 281 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
01/01/2018 HUMALOG JUNIOR KWIKPEN
insulin lispro ADD UM: QUANTITY 30 / 30 days
01/01/2018 HUMALOG JUNIOR KWIKPEN
insulin lispro ADD UM: AGE Up to 21 yrs old
01/01/2018 glatiramer acetate
glatiramer acetate ADD TO FORMULARY Covered
01/01/2018 glatiramer acetate
glatiramer acetate ADD UM: QUANTITY 12 / 28 days
01/01/2018 methergine methylergonovine maleate ADD TO FORMULARY Covered 01/01/2018 metanx,l-
methylfolate ca p- 5-p me- cbl,foltanx rf,levomefol- pyridoxal-mec- algal
levomefolate calc/pyridoxal phos/mecobalamin/schiz.alg al oil
REMOVE FROM FORMULARY
Non-Formulary
01/01/2018 etidronate disodium,didronel
etidronate disodium REMOVE FROM FORMULARY
Covered Non-Formulary
01/01/2018 didronel,etidronat e disodium
etidronate disodium REMOVE FROM FORMULARY
Non-Formulary
01/01/2018 FARXIGA dapagliflozin propanediol REMOVE FROM FORMULARY
Covered Non-Formulary
01/01/2018 ASACOL HD mesalamine REMOVE FROM FORMULARY
Non-Formulary
01/01/2018 ASACOL HD mesalamine REMOVE UM: QUANTITY
01/01/2018 DUPIXENT dupilumab REMOVE FROM FORMULARY
Non-Formulary
01/01/2018 ELLZIA PAK triamcinolone acetonide/dimethicone
REMOVE FROM FORMULARY
Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 282 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
01/01/2018 FLONASE SENSIMIST,CHI LDREN'S FLONASE SENSIMIST
fluticasone furoate REMOVE FROM FORMULARY
Non-Formulary
01/01/2018 INGREZZA valbenazine tosylate REMOVE FROM FORMULARY
Non-Formulary
01/01/2018 RHOFADE oxymetazoline hcl REMOVE FROM FORMULARY
Non-Formulary
01/01/2018 RYVENT carbinoxamine maleate REMOVE FROM FORMULARY
Non-Formulary
01/01/2018 SILIQ brodalumab REMOVE FROM FORMULARY
Non-Formulary
01/01/2018 VYVANSE lisdexamfetamine dimesylate
REMOVE FROM FORMULARY
Non-Formulary
01/01/2018 VYVANSE lisdexamfetamine dimesylate
CHANGE UM: CUSTOM Carve-out Drug Bill MDCH FFS
01/01/2018 TWINRIX hepatitis a virus and hepatitis b virus vaccine/pf,hepatitis a virus & hepatitis b virus vaccine/pf
ADD TO FORMULARY Covered
01/01/2018 TWINRIX hepatitis a virus and hepatitis b virus vaccine/pf,hepatitis a virus & hepatitis b virus vaccine/pf
ADD UM: AGEQUANTITY At least 19 yrs old; 2 / lifetime
01/01/2018 TWINRIX hepatitis a virus and hepatitis b virus vaccine/pf
ADD TO FORMULARY Covered
01/01/2018 TWINRIX hepatitis a virus and hepatitis b virus vaccine/pf
ADD UM: AGEQUANTITY At least 19 yrs old; 2 / lifetime
01/01/2018 HAVRIX hepatitis a virus vaccine/pf ADD TO FORMULARY Covered 01/01/2018 HAVRIX hepatitis a virus vaccine/pf ADD UM: AGEQUANTITY At least 19 yrs
old; 2 / lifetime
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 283 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
01/01/2018 HAVRIX hepatitis a virus vaccine/pf ADD TO FORMULARY Covered 01/01/2018 HAVRIX hepatitis a virus vaccine/pf ADD UM: AGEQUANTITY At least 19 yrs
old; 2 / lifetime 01/01/2018 HAVRIX hepatitis a virus vaccine/pf ADD TO FORMULARY Covered 01/01/2018 HAVRIX hepatitis a virus vaccine/pf ADD UM: AGEQUANTITY At least 19 yrs
old; 2 / lifetime 01/01/2018 VAQTA hepatitis a virus vaccine/pf ADD TO FORMULARY Covered 01/01/2018 VAQTA hepatitis a virus vaccine/pf ADD UM: AGEQUANTITY At least 19 yrs
old; 2 / lifetime 01/01/2018 VAQTA hepatitis a virus vaccine/pf ADD TO FORMULARY Covered 01/01/2018 VAQTA hepatitis a virus vaccine/pf ADD TO FORMULARY Covered 01/01/2018 VAQTA hepatitis a virus vaccine/pf ADD UM: AGEQUANTITY At least 19 yrs
old; 2 / lifetime 01/01/2018 VAQTA hepatitis a virus vaccine/pf ADD TO FORMULARY Covered 01/01/2018 VAQTA hepatitis a virus vaccine/pf ADD UM: AGEQUANTITY At least 19 yrs
old; 2 / lifetime 01/01/2018 piroxicam piroxicam ADD TO FORMULARY Covered 01/01/2018 piroxicam piroxicam ADD TO FORMULARY Covered 01/01/2018 HAVRIX hepatitis a virus vaccine/pf ADD TO FORMULARY Covered 01/01/2018 HAVRIX hepatitis a virus vaccine/pf ADD UM: AGEQUANTITY At least 19 yrs
old; 2 / 1 lifetime 01/01/2018 VAQTA hepatitis a virus vaccine/pf ADD UM: AGEQUANTITY At least 19 yrs
old; 2 / 1 lifetime 01/01/2018 TWINRIX hepatitis a virus and
hepatitis b virus vaccine/pf REMOVE FROM
FORMULARY Covered Non-Formulary
01/01/2018 TWINRIX hepatitis a virus and hepatitis b virus vaccine/pf
REMOVE UM: AGEQUANTITY
At least 19 yrs old; 2 / lifetime
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 284 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
01/01/2018 copaxone,glatopa ,glatiramer acetate
glatiramer acetate ADD TO FORMULARY Covered
01/01/2018 copaxone,glatopa ,glatiramer acetate
glatiramer acetate CHANGE UM: QUANTITY 1 / days
01/01/2018 COPAXONE glatiramer acetate REMOVE FROM FORMULARY
Covered Non-Formulary
01/02/2018 tacrolimus tacrolimus REMOVE UM: AUTHORIZATION
PA applies
01/02/2018 tacrolimus tacrolimus REMOVE UM: AUTHORIZATION
PA applies
01/02/2018 JARDIANCE empagliflozin CHANGE TIER Covered 01/02/2018 JARDIANCE empagliflozin CHANGE UM: QUANTITY 30 / 30 days 01/02/2018 JARDIANCE empagliflozin ADD UM: AUTHORIZATION PA applies 01/02/2018 JARDIANCE empagliflozin CHANGE TIER Covered 01/02/2018 JARDIANCE empagliflozin CHANGE UM: QUANTITY 30 / 30 days 01/02/2018 JARDIANCE empagliflozin ADD UM: AUTHORIZATION PA applies 01/02/2018 SYNJARDY empagliflozin/metformin hcl CHANGE UM: QUANTITY 60 / 30 days 2 / 1 days 01/02/2018 SYNJARDY empagliflozin/metformin hcl CHANGE UM: QUANTITY 2 / 1 days 01/02/2018 SYNJARDY empagliflozin/metformin hcl CHANGE UM: QUANTITY 60 / 30 days 2 / 1 days 01/02/2018 SYNJARDY empagliflozin/metformin hcl CHANGE UM: QUANTITY 60 / 30 days 2 / 1 days 01/02/2018 SYNJARDY XR empagliflozin/metformin hcl CHANGE UM: QUANTITY 30 / 30 days 1 / 1 days 01/02/2018 SYNJARDY XR empagliflozin/metformin hcl CHANGE UM: QUANTITY 60 / 30 days 2 / 1 days 01/02/2018 SYNJARDY XR empagliflozin/metformin hcl CHANGE UM: QUANTITY 30 / 30 days 1 / 1 days 01/02/2018 SYNJARDY XR empagliflozin/metformin hcl CHANGE UM: QUANTITY 60 / 30 days 2 / 1 days 01/09/2018 FARXIGA dapagliflozin propanediol REMOVE UM:
AUTHORIZATION PA applies
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 285 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
01/09/2018 FARXIGA dapagliflozin propanediol REMOVE UM: AUTHORIZATION
PA applies
01/09/2018 gengraf,neoral,cy closporine modified,cyclosp orine
cyclosporine, modified REMOVE UM: QUANTITY
01/15/2018 DELZICOL mesalamine REMOVE FROM FORMULARY
Covered Non-Formulary
01/15/2018 DELZICOL mesalamine ADD UM: QUANTITY 6 / 1 days 01/15/2018 APRISO mesalamine ADD UM: QUANTITY 4 / 1 days 01/15/2018 HEMLIBRA emicizumab-kxwh ADD UM: CUSTOM Carveout Drug -
Bill MDCH FFS 01/19/2018 celebrex,celecoxi
b celecoxib REMOVE UM:
AUTHORIZATION
01/23/2018 ibuprofen,ibuprof en jr
ibuprofen CHANGE TIER Covered
01/23/2018 ibuprofen ibuprofen ADD TO FORMULARY Covered 01/29/2018 VAQTA hepatitis a virus vaccine/pf ADD UM: AGEQUANTITY At least 19 yrs
old; 2 / lifetime 01/31/2018 feldene,piroxicam piroxicam ADD UM: QUANTITY 30 / 30 days 01/31/2018 feldene,piroxicam piroxicam ADD UM: QUANTITY 30 / 30 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 286 UPDATED 10/2018
February, 2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/01/2018 QVAR
REDIHALER beclomethasone dipropionate
ADD TO FORMULARY Non-Formulary Covered
02/01/2018 QVAR REDIHALER
beclomethasone dipropionate
ADD UM: QUANTITY 10.6 / 30 days
02/01/2018 QVAR REDIHALER
beclomethasone dipropionate
ADD TO FORMULARY Non-Formulary Covered
02/01/2018 QVAR REDIHALER
beclomethasone dipropionate
ADD UM: QUANTITY 10.6 / 30 days
02/01/2018 estradiol estradiol ADD TO FORMULARY Covered 02/01/2018 estradiol estradiol ADD UM: QUANTITY 42.5 / 30 days 02/01/2018 estradiol estradiol ADD UM: GENDER Female 02/01/2018 ESTRACE estradiol REMOVE FROM
FORMULARY Covered Non-Formulary
02/01/2018 ESTRACE estradiol REMOVE UM: GENDER Female
02/01/2018 ESTRACE estradiol REMOVE UM: QUANTITY 42.5 / 30 days
02/01/2018 FLUVIRIN 2016- 2017
influenza virus vaccine trival 2016-2017 (4yr and older)/pf
REMOVE FROM FORMULARY
Covered Non-Formulary
02/01/2018 FLUVIRIN 2016- 2017
influenza virus vaccine trival 2016-2017 (4yr and older)/pf
REMOVE UM: QUANTITY 1 / 270 days
02/01/2018 FLUVIRIN 2016- 2017
influenza virus vaccine trivalent 2016-2017 (4 yr and older)
REMOVE FROM FORMULARY
Covered Non-Formulary
02/01/2018 FLUVIRIN 2016- 2017
influenza virus vaccine trivalent 2016-2017 (4 yr and older)
REMOVE UM: QUANTITY 1 / 270 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 287 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
02/01/2018 FLUMIST QUAD 2017-2018
influenza vaccine quadrivalent live 2017-2018 (2 yrs-49 yrs)
ADD TO FORMULARY Covered
02/01/2018 FLUZONE QUAD PEDI 2016-2017
influenza virus vaccine quadrival 2016-17 (6 mos- 35 mos)/pf
REMOVE FROM FORMULARY
Covered Non-Formulary
02/01/2018 FLUZONE INTRADERM QUAD 2016-17
influenza virus vaccine quadrivalent 2016-17(18yrs- 64yrs)/pf
REMOVE FROM FORMULARY
Covered Non-Formulary
02/01/2018 FLUARIX QUAD 2016- 2017,FLUZONE QUAD 2016- 2017
influenza virus vaccine quadval split 2016-17(36 mos up)/pf
REMOVE FROM FORMULARY
Covered Non-Formulary
02/01/2018 FLUARIX QUAD 2016- 2017,FLUZONE QUAD 2016- 2017
influenza virus vaccine quadval split 2016-17(36 mos up)/pf
REMOVE UM: QUANTITY
02/01/2018 FLULAVAL QUAD 2016- 2017,FLUZONE QUAD 2016- 2017
influenza virus vaccine qvalsplit 2016-2017(6 mos and older)
REMOVE FROM FORMULARY
Covered Non-Formulary
02/01/2018 FLULAVAL QUAD 2016- 2017,FLUZONE QUAD 2016- 2017
influenza virus vaccine qvalsplit 2016-2017(6 mos and older)
REMOVE UM: QUANTITY
02/01/2018 FLULAVAL QUAD 2016- 2017
influenza virus vaccine qvalsplit 2016-2017(6 mos and up)/pf
REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 288 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
02/01/2018 FLULAVAL QUAD 2016- 2017
influenza virus vaccine qvalsplit 2016-2017(6 mos and up)/pf
REMOVE UM: QUANTITY 1 / 270 days
02/01/2018 FLUZONE HIGH- DOSE 2016-2017
influenza virus vaccine trival split 2016-2017(65 yr up)/pf
REMOVE FROM FORMULARY
Covered Non-Formulary
02/01/2018 FLUZONE HIGH- DOSE 2016-2017
influenza virus vaccine trival split 2016-2017(65 yr up)/pf
REMOVE UM: QUANTITY 1 / 270 days
02/01/2018 AFLURIA 2016- 2017,EZ FLU 2016-2017 (AFLURIA)
influenza virus vaccine trivalent 2016-2017 (5 years up)/pf
REMOVE FROM FORMULARY
Non-Formulary
02/01/2018 AFLURIA 2016- 2017,EZ FLU 2016-2017 (AFLURIA)
influenza virus vaccine trivalent 2016-2017 (5 years up)/pf
REMOVE UM: QUANTITY
02/01/2018 AFLURIA 2016- 2017
influenza virus vaccine trivalent 2016-2017 (5 yr and older)
REMOVE FROM FORMULARY
Covered Non-Formulary
02/01/2018 AFLURIA 2016- 2017
influenza virus vaccine trivalent 2016-2017 (5 yr and older)
REMOVE UM: QUANTITY 1 / 270 days
02/01/2018 FLUBLOK 2016- 2017
influenza virus vaccine tv 2016-17(18 yrs and older)rcmb/pf
REMOVE FROM FORMULARY
Covered Non-Formulary
02/01/2018 LYRICA CR pregabalin ADD UM: CUSTOM Carveout Drug - Bill MDCH FFS
02/05/2018 brisdelle,paroxeti ne mesylate
paroxetine mesylate CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 289 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
02/14/2018 xanax,xanax xr,alprazolam intensol,diazepa m,lorazepam intensol,lorazepa m,alprazolam er,valium,oxazep am,alprazolam,al prazolam odt,clorazepate dipotassium,chlor diazepoxide hcl,alprazolam xr,ativan,tranxen e t-tab
alprazolam,diazepam,loraze pam,oxazepam,clorazepate dipotassium,chlordiazepoxid e hcl
CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
02/14/2018 halcion,midazola m hcl,triazolam,esta zolam,temazepa m,flurazepam hcl,restoril,loraze pam,ativan,loraze pam-0.9% nacl,lorazepam- ns,lorazepam- d5w,doral,quazep am
triazolam,midazolam hcl,estazolam,temazepam,fl urazepam hcl,lorazepam,lorazepam in 0.9 % sodium chloride,lorazepam in 5 % dextrose and water,quazepam
CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
02/14/2018 klonopin,clonaze pam,diazepam,di astat acudial,diastat,on fi
clonazepam,diazepam,cloba zam
CHANGE UM: CUSTOM Carveout Drug - Bill MDCH FFS
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 290 UPDATED 10/2018
March, 2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2018 MYALEPT metreleptin ADD TO FORMULARY Not Covered 03/01/2018 MYALEPT metreleptin ADD UM: CUSTOM Carve Out Drug -
Bill MDHHS FFS 03/02/2018 vitamin d3,delta
d3,vitamin d,vitamin d-400
cholecalciferol (vitamin d3),ergocalciferol (vitamin d2)
REMOVE UM: AGE
03/02/2018 MYALEPT metreleptin REMOVE FROM FORMULARY
Not Covered Non-Formulary
03/03/2018 vitamin d3,delta d3,vitamin d,vitamin d-400
cholecalciferol (vitamin d3),ergocalciferol (vitamin d2)
ADD UM: AGE At least 65 yrs old
03/05/2018 gentle laxative,bisacodyl ,bisac- evac,biscolax,lax ative suppository,fast relief laxative,dulcolax, magic bullet
bisacodyl REMOVE UM: QUANTITY
03/11/2018 i-vite,opti- vitamin,antioxida nt vitamins,ocuvite with lutein,healthy eyes,eye health plus lutein,vision vitamins,vision formula,vision formula with lutein
beta-carotene(a) w-c and e/lutein/minerals,beta- carotene(a) w-c & e/lutein/minerals
REMOVE FROM FORMULARY
Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 291 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
03/22/2018 ibuprofen ibuprofen CHANGE TIER Covered 03/31/2018 esgic,butalbital-
acetaminophen- caffe,margesic,al agesic,anolor- 300,capacet,triad ,medigesic,zebut al
butalbital/acetaminophen/caf feine
REMOVE FROM FORMULARY
Non-Formulary
03/31/2018 esgic,butalbital- acetaminophen- caffe,margesic,al agesic,anolor- 300,capacet,triad ,medigesic,zebut al
butalbital/acetaminophen/caf feine
REMOVE UM: CUSTOM
03/31/2018 esgic,butalbital- acetaminophen- caffe,margesic,al agesic,anolor- 300,capacet,triad ,medigesic,zebut al
butalbital/acetaminophen/caf feine
REMOVE UM: AGE 10 to 64 yrs old
03/31/2018 esgic,butalbital- acetaminophen- caffe,margesic,al agesic,anolor- 300,capacet,triad ,medigesic,zebut al
butalbital/acetaminophen/caf feine
REMOVE UM: QUANTITY
03/31/2018 ketoprofen ketoprofen REMOVE FROM FORMULARY
Covered Non-Formulary
03/31/2018 ketoprofen ketoprofen REMOVE FROM FORMULARY
Covered Non-Formulary
03/31/2018 diskets,methados e,methadone hcl
methadone hcl REMOVE FROM FORMULARY
Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 292 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
03/31/2018 diskets,methados e,methadone hcl
methadone hcl REMOVE UM: CUSTOM
03/31/2018 diskets,methados e,methadone hcl
methadone hcl REMOVE UM: QUANTITY 3 / days
03/31/2018 THERMAZENE silver sulfadiazine REMOVE FROM FORMULARY
Covered Non-Formulary
03/31/2018 lidoderm,lidocain e
lidocaine REMOVE FROM FORMULARY
Non-Formulary
03/31/2018 lidoderm,lidocain e
lidocaine REMOVE UM: AUTHORIZATION
03/31/2018 lidamantle,lidocai ne hcl,lidopin,cidalea ze
lidocaine hcl REMOVE FROM FORMULARY
Non-Formulary
03/31/2018 methylergonovine maleate
methylergonovine maleate REMOVE UM: AGE At least 12 yrs old
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 293 UPDATED 10/2018
April, 2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/01/2018 naproxen naproxen ADD UM: AGE Up to 12 yrs old 04/01/2018 naproxen naproxen ADD TO FORMULARY Non-Formulary Covered 04/01/2018 sumatriptan sumatriptan ADD TO FORMULARY Covered 04/01/2018 sumatriptan sumatriptan ADD UM: QUANTITY 1 / 30 days 04/01/2018 sumatriptan sumatriptan ADD TO FORMULARY Covered 04/01/2018 sumatriptan sumatriptan ADD UM: QUANTITY 1 / 30 days 04/01/2018 ssd silver sulfadiazine ADD TO FORMULARY Non-Formulary Covered 04/01/2018 diclofenac
sodium diclofenac sodium ADD UM: QUANTITY 100 / 30 days
04/01/2018 diclofenac sodium
diclofenac sodium ADD TO FORMULARY Covered
04/01/2018 methergine methylergonovine maleate ADD UM: QUANTITY 28 / 180 days 04/01/2018 ODOMZO sonidegib phosphate ADD TO FORMULARY Covered 04/01/2018 TYMLOS abaloparatide ADD TO FORMULARY Covered 04/01/2018 TRACLEER bosentan ADD TO FORMULARY Covered 04/01/2018 TRACLEER bosentan ADD UM: AGE 3.0 to 12.0 yrs
old 04/01/2018 ZENPEP lipase/protease/amylase ADD TO FORMULARY Covered 04/01/2018 ZENPEP lipase/protease/amylase ADD UM: QUANTITY 480 / 30 days 04/01/2018 ZENPEP lipase/protease/amylase ADD UM: QUANTITY 480 / 30 days 04/01/2018 ZENPEP lipase/protease/amylase ADD TO FORMULARY Covered 04/01/2018 aspercreme lidocaine ADD TO FORMULARY Covered 04/01/2018 aspercreme lidocaine ADD UM: QUANTITY 30 / 30 days 04/01/2018 amantadine amantadine hcl ADD UM: QUANTITY 4 / 1 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 294 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
04/01/2018 ENBREL MINI etanercept ADD UM: CUSTOM Must be used with AutoTouch
reusable Autoinjector NDC 58406-4700-01
04/01/2018 HAEGARDA c1 esterase inhibitor ADD UM: CUSTOM Carveout Drug - Bill MDCH FFS
04/01/2018 HAEGARDA c1 esterase inhibitor ADD UM: CUSTOM Carveout Drug - Bill MDCH FFS
04/01/2018 MYDAYIS dextroamphetamine sulf- saccharate/amphetamine sulf-aspartate
ADD UM: CUSTOM Carveout Drug - Bill MDCH FFS
04/01/2018 MYDAYIS dextroamphetamine sulf- saccharate/amphetamine sulf-aspartate
ADD UM: CUSTOM Carveout Drug - Bill MDCH FFS
04/01/2018 MYDAYIS dextroamphetamine sulf- saccharate/amphetamine sulf-aspartate
ADD UM: CUSTOM Carveout Drug - Bill MDCH FFS
04/01/2018 MYDAYIS dextroamphetamine sulf- saccharate/amphetamine sulf-aspartate
ADD UM: CUSTOM Carveout Drug - Bill MDCH FFS
04/01/2018 namenda,meman tine hcl
memantine hcl REMOVE UM: AUTHORIZATION
04/01/2018 TRACLEER bosentan REMOVE UM: AUTHORIZATION
PA applies
04/01/2018 TRACLEER bosentan REMOVE UM: AUTHORIZATION
PA applies
04/01/2018 ENBREL MINI etanercept REMOVE FROM FORMULARY
Non-Formulary
04/01/2018 BENLYSTA belimumab REMOVE FROM FORMULARY
Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 295 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
04/01/2018 CINRYZE,BERIN ERT,HAEGARDA
c1 esterase inhibitor REMOVE FROM FORMULARY
Non-Formulary
04/01/2018 INTRAROSA prasterone (dhea) REMOVE FROM FORMULARY
Non-Formulary
04/01/2018 KEVZARA sarilumab REMOVE FROM FORMULARY
Non-Formulary
04/01/2018 MORPHABOND ER
morphine sulfate REMOVE FROM FORMULARY
Non-Formulary
04/01/2018 MORPHABOND ER
morphine sulfate REMOVE FROM FORMULARY
Non-Formulary
04/01/2018 diclofenac sodium
diclofenac sodium REMOVE UM: AUTHORIZATION
04/01/2018 lidocare,aspercre me
lidocaine CHANGE TIER Covered
04/01/2018 lidocare,aspercre me
lidocaine CHANGE UM: QUANTITY 30 / 30 days
04/01/2018 lidocare lidocaine REMOVE FROM FORMULARY
Covered Non-Formulary
04/01/2018 lidocare lidocaine REMOVE UM: QUANTITY 30 / 30 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 296 UPDATED 10/2018
May, 2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/10/2018 imitrex,sumatripta
n sumatriptan CHANGE UM: QUANTITY 6 / 30 days
05/10/2018 imitrex,sumatripta n
sumatriptan CHANGE UM: QUANTITY 6 / 30 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 297 UPDATED 10/2018
June, 2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/21/2018 NORVIR ritonavir ADD UM: CUSTOM MDHHS Carve-
Out 06/21/2018 reyataz,invirase,c
rixivan,norvir,lexiv a,viracept,evotaz, fosamprenavir calcium,atazanav ir sulfate,ritonavir
atazanavir sulfate,saquinavir mesylate,indinavir sulfate,ritonavir,fosamprena vir calcium,nelfinavir mesylate,atazanavir sulfate/cobicistat
CHANGE UM: CUSTOM MDHHS Carve- Out
06/30/2018 QVAR beclomethasone dipropionate
REMOVE FROM FORMULARY
Covered Non-Formulary
06/30/2018 QVAR beclomethasone dipropionate
REMOVE UM: QUANTITY 8.7 / 30 days
06/30/2018 QVAR beclomethasone dipropionate
REMOVE FROM FORMULARY
Covered Non-Formulary
06/30/2018 QVAR beclomethasone dipropionate
REMOVE UM: QUANTITY 8.7 / 30 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 298 UPDATED 10/2018
July, 2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2018 imitrex,sumatripta
n sumatriptan CHANGE UM: QUANTITY 6 / 30 days
07/01/2018 estradiol estradiol ADD TO FORMULARY Covered 07/01/2018 yuvafem estradiol CHANGE TIER Covered 07/01/2018 RANEXA ranolazine ADD UM: QUANTITY 2 / 1 days 07/01/2018 prenatal
complete prenatal vits with calcium no.21/ferrous fumarate/folic acid
ADD UM: QUANTITY 1 / 1 days
07/01/2018 prenatal complete
prenatal vits with calcium no.21/ferrous fumarate/folic acid
ADD UM: AGE 12 to 55 yrs old
07/01/2018 prenatal complete
prenatal vits with calcium no.21/ferrous fumarate/folic acid
ADD UM: GENDER Female
07/01/2018 se-natal 19,prenatal 19,thrivite 19
prenatal vits no.119/iron fumarate/folic acid/docusate sod.,multivit-mins no.59/ferrous fumarate/folic acid/docusate sod
ADD UM: QUANTITY 1 / 1 days
07/01/2018 se-natal 19,prenatal 19,thrivite 19
prenatal vits no.119/iron fumarate/folic acid/docusate sod.,multivit-mins no.59/ferrous fumarate/folic acid/docusate sod
ADD UM: AGE 12 to 55 yrs old
07/01/2018 se-natal 19,prenatal 19,thrivite 19
prenatal vits no.119/iron fumarate/folic acid/docusate sod.,multivit-mins no.59/ferrous fumarate/folic acid/docusate sod
ADD UM: GENDER Female
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 299 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
07/01/2018 prenatal prenatal vitamins no.62/folic acid/omega-3s/dha/epa/fish oil
ADD UM: QUANTITY 1 / 1 days
07/01/2018 prenatal prenatal vitamins no.62/folic acid/omega-3s/dha/epa/fish oil
ADD UM: AGE 12 to 55 yrs old
07/01/2018 prenatal prenatal vitamins no.62/folic acid/omega-3s/dha/epa/fish oil
ADD UM: GENDER Female
07/01/2018 OTEZLA apremilast CHANGE UM: QUANTITY 1 / lifetime 1 / 365 days 07/01/2018 OTEZLA apremilast CHANGE UM: QUANTITY 1 / lifetime 1 / 365 days 07/01/2018 ketone test strip urine acetone test,strips REMOVE FROM
FORMULARY Covered Non-Formulary
07/01/2018 ketone care test strip,ketone test strip
urine acetone test,strips REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2018 chemstrip k urine acetone test,strips REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2018 ketostix reagent urine acetone test,strips REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2018 trueplus ketone test strip
urine acetone test,strips REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2018 single use swab alcohol antiseptic pads REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2018 iv prep wipes,iv antiseptic wipes
alcohol antiseptic pads REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2018 alcohol prep pads,alcohol pads
alcohol antiseptic pads REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2018 ultilet alcohol swab
alcohol antiseptic pads REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 300 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
07/01/2018 curity alcohol preps
alcohol antiseptic pads REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2018 alcohol prep swabs
alcohol antiseptic pads REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2018 alcohol swabs,alcohol swab
alcohol antiseptic pads REMOVE FROM FORMULARY
Non-Formulary
07/01/2018 alcohol prep pads alcohol antiseptic pads REMOVE FROM FORMULARY
Non-Formulary
07/01/2018 alcohol wipes alcohol antiseptic pads REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2018 webcol alcohol antiseptic pads REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2018 sure-prep alcohol prep pads
alcohol antiseptic pads REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2018 sure comfort alcohol
alcohol antiseptic pads REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2018 easy touch alcohol prep pads
alcohol antiseptic pads REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2018 incontrol alcohol pads
alcohol antiseptic pads REMOVE FROM FORMULARY
Non-Formulary
07/01/2018 pro comfort alcohol pads
alcohol antiseptic pads REMOVE FROM FORMULARY
Non-Formulary
07/01/2018 caretouch alcohol prep pad
alcohol antiseptic pads REMOVE FROM FORMULARY
Non-Formulary
07/01/2018 BENZNIDAZOLE benznidazole ADD UM: AUTHORIZATION PA applies 07/01/2018 ARMONAIR
RESPICLICK fluticasone propionate ADD TO FORMULARY Covered
07/01/2018 ARMONAIR RESPICLICK
fluticasone propionate ADD TO FORMULARY Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 301 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
07/01/2018 ARMONAIR RESPICLICK
fluticasone propionate ADD TO FORMULARY Covered
07/01/2018 ARMONAIR RESPICLICK
fluticasone propionate ADD UM: QUANTITY 1 / 30 days
07/01/2018 ARMONAIR RESPICLICK
fluticasone propionate ADD UM: QUANTITY 1 / 30 days
07/01/2018 ARMONAIR RESPICLICK
fluticasone propionate ADD UM: QUANTITY 1 / 30 days
07/01/2018 FLOVENT HFA fluticasone propionate ADD TO FORMULARY Covered 07/01/2018 FLOVENT HFA fluticasone propionate ADD TO FORMULARY Covered 07/01/2018 FLOVENT HFA fluticasone propionate ADD UM: QUANTITY 1 / 30 days 07/01/2018 FLOVENT HFA fluticasone propionate ADD UM: AGE 0 to 12 yrs old 07/01/2018 FLOVENT HFA fluticasone propionate ADD UM: QUANTITY 1 / 30 days 07/01/2018 FLOVENT HFA fluticasone propionate ADD UM: AGE 0 to 12 yrs old 07/01/2018 BENZNIDAZOLE benznidazole ADD TO FORMULARY Covered 07/01/2018 BENZNIDAZOLE benznidazole ADD TO FORMULARY Covered 07/01/2018 BENZNIDAZOLE benznidazole ADD UM: AUTHORIZATION PA applies 07/01/2018 nicotine patch nicotine CHANGE UM: QUANTITY 1 / Day 56 / 56 days 07/01/2018 neomycin-
polymyxin-hc neomycin sulfate/polymyxin b sulfate/hydrocortisone
REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2018 ENDARI glutamine ADD TO FORMULARY Covered 07/01/2018 ENDARI glutamine ADD UM: AUTHORIZATION PA applies 07/01/2018 nitroglycerin nitroglycerin CHANGE TIER Covered 07/01/2018 nitrolingual,nitrogl
ycerin nitroglycerin ADD UM: STEP ST applies
07/01/2018 QBRELIS lisinopril ADD TO FORMULARY Covered 07/01/2018 QBRELIS lisinopril ADD UM: AGE 0 to 12 yrs old
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 302 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
07/01/2018 pindolol pindolol REMOVE FROM FORMULARY
Non-Formulary
07/01/2018 pindolol pindolol REMOVE FROM FORMULARY
Non-Formulary
07/01/2018 timolol maleate timolol maleate REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2018 timolol maleate timolol maleate REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2018 timolol maleate timolol maleate REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2018 amlodipine- valsartan
amlodipine besylate/valsartan
ADD TO FORMULARY Covered
07/01/2018 amlodipine- valsartan
amlodipine besylate/valsartan
ADD TO FORMULARY Covered
07/01/2018 amlodipine- valsartan
amlodipine besylate/valsartan
ADD TO FORMULARY Covered
07/01/2018 amlodipine- valsartan
amlodipine besylate/valsartan
ADD TO FORMULARY Covered
07/01/2018 dipyridamole,pers antine
dipyridamole ADD UM: QUANTITY 4 / 1 days
07/01/2018 aspirin ec aspirin CHANGE TIER Covered 07/01/2018 adult aspirin
regimen,adult aspirin
aspirin ADD TO FORMULARY Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 303 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
07/01/2018 aspirin ec,ecotrin,low dose aspirin ec,aspir-low,lo- dose aspirin ec,adult low dose aspirin ec,miniprin,halfpri n,aspir 81,st. joseph aspirin ec,adult low strength aspirin,aspirin,st joseph aspirin,adult low strength,adult aspirin regimen,adult aspirin
aspirin CHANGE UM: QUANTITY 1 / 1 days
07/01/2018 aspirin,children's aspirin
aspirin CHANGE TIER Covered
07/01/2018 ELIQUIS apixaban REMOVE UM: QUANTITY 2 / 1 days
07/01/2018 ELIQUIS apixaban REMOVE UM: QUANTITY 2 / 1 days
07/01/2018 PRENATE AM prenatal vit 114/methyltetrahydfolate gluc,folic acid/ginger
REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2018 multivitamins- a,b,d,e,k,zn
pediatric multivit no.22/cholecalciferol(d3)/ph ytonadione(k)
ADD TO FORMULARY Covered
07/01/2018 tri-vit with fluoride-iron
fluoride/iron/vitamins a,c,and d
ADD TO FORMULARY Covered
07/01/2018 vitamins a,c,d and fluoride,vitamins a,d,c and fluoride
pediatric multivit with a,c,d3 no.21/sodium fluoride
CHANGE TIER Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 304 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
07/01/2018 tri-vitamin with fluoride,vitamins a,c,d and fluoride,vitamins a,d,c and fluoride,triple- vitamin w- fluoride,tri- vitamin-fluoride
pediatric multivit with a,c,d3 no.21/sodium fluoride,pediatric multivitamins a,c,& d3 no.21 with sodium fluoride,fluoride/vitamins a,c,and d
CHANGE UM: QUANTITY 2 / 1 days
07/01/2018 tri-vitamin with fluoride,vitamins a,c,d and fluoride,vitamins a,d,c and fluoride,triple- vitamin w- fluoride,tri- vitamin-fluoride
pediatric multivit with a,c,d3 no.21/sodium fluoride,pediatric multivitamins a,c,& d3 no.21 with sodium fluoride,fluoride/vitamins a,c,and d
ADD UM: AGE 0 to 12 yrs old
07/01/2018 tri-vitamin with fluoride,tri- vitamins with fluoride
pediatric multivit with a,c,d3 no.21/sodium fluoride,pediatric multivitamins a,c,& d3 no.21 with sodium fluoride,fluoride/vitamins a,c,and d
CHANGE UM: QUANTITY 2 / Day 2 / 1 days
07/01/2018 tri-vitamin with fluoride,tri- vitamins with fluoride
pediatric multivit with a,c,d3 no.21/sodium fluoride,pediatric multivitamins a,c,& d3 no.21 with sodium fluoride,fluoride/vitamins a,c,and d
ADD UM: AGE 0 to 12 yrs old
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 305 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
07/01/2018 tri-vitamin with fluoride,tri- vitamins with fluoride
pediatric multivit with a,c,d3 no.21/sodium fluoride,pediatric multivitamins a,c,& d3 no.21 with sodium fluoride,fluoride/vitamins a,c,and d
REMOVE UM: CUSTOM Covered for CSHCS Only
07/01/2018 tri-vit with fluoride-iron,tri- vitamin with iron- fluoride
fluoride/iron/vitamins a,c,and d
ADD UM: QUANTITY 2 / 1 days
07/01/2018 tri-vit with fluoride-iron,tri- vitamin with iron- fluoride
fluoride/iron/vitamins a,c,and d
ADD UM: AGE 0 to 12 yrs old
07/01/2018 tri-vit with fluoride-iron,tri- vitamin with iron- fluoride
fluoride/iron/vitamins a,c,and d
REMOVE UM: CUSTOM Covered for CSHCS Only
07/01/2018 multivitamins with fluoride,multivita min with fluoride,mvc- fluoride
pediatric multivitamins combination no.12/sodium fluoride,pediatric multivitamin no.12 with sodium fluoride,pediatric multivitamins no.17 with sodium fluoride
ADD UM: QUANTITY 1 / 1 days
07/01/2018 multivitamins with fluoride,multivita min with fluoride,mvc- fluoride
pediatric multivitamins combination no.12/sodium fluoride,pediatric multivitamin no.12 with sodium fluoride,pediatric multivitamins no.17 with sodium fluoride
ADD UM: AGE 0 to 12 yrs old
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 306 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
07/01/2018 multivitamins with fluoride,multivita min with fluoride,mvc- fluoride
pediatric multivitamins combination no.12/sodium fluoride,pediatric multivitamin no.12 with sodium fluoride
ADD UM: QUANTITY 1 / 1 days
07/01/2018 multivitamins with fluoride,multivita min with fluoride,mvc- fluoride
pediatric multivitamins combination no.12/sodium fluoride,pediatric multivitamin no.12 with sodium fluoride
ADD UM: AGE 0 to 12 yrs old
07/01/2018 multivitamins with fluoride,multivita min with fluoride,mvc- fluoride
pediatric multivitamins combination no.12/sodium fluoride,pediatric multivitamin no.12 with sodium fluoride
ADD UM: QUANTITY 1 / 1 days
07/01/2018 multivitamins with fluoride,multivita min with fluoride,mvc- fluoride
pediatric multivitamins combination no.12/sodium fluoride,pediatric multivitamin no.12 with sodium fluoride
ADD UM: AGE 0 to 12 yrs old
07/01/2018 multivitamins with fluoride,multivita min with fluoride
pediatric multivitamins combination no.12/sodium fluoride,pediatric multivitamins no.17 with sodium fluoride,pediatric multivitamin no.16/sodium fluoride,multivitamins with fluoride
ADD TO FORMULARY Covered
07/01/2018 multivitamins with fluoride,multivita min with fluoride
pediatric multivitamin no.16/sodium fluoride,pediatric multivitamins no.16 with sodium fluoride
ADD UM: QUANTITY 1 / 1 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 307 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
07/01/2018 multivitamins with fluoride,multivita min with fluoride
pediatric multivitamin no.16/sodium fluoride,pediatric multivitamins no.16 with sodium fluoride
ADD UM: AGE 0 to 12 yrs old
07/01/2018 multivitamins with fluoride,multivita min with fluoride
pediatric multivitamin no.16/sodium fluoride,pediatric multivitamins no.16 with sodium fluoride
REMOVE UM: CUSTOM
07/01/2018 multivitamins with fluoride,multivita min with fluoride,multi- vitamin with fluoride
pediatric multivitamins no.17 with sodium fluoride
ADD UM: QUANTITY 1 / 1 days
07/01/2018 multivitamins with fluoride,multivita min with fluoride,multi- vitamin with fluoride
pediatric multivitamins no.17 with sodium fluoride
ADD UM: AGE 0 to 12 yrs old
07/01/2018 multivitamins with fluoride,multivita min with fluoride,multi- vitamin with fluoride
pediatric multivitamins no.17 with sodium fluoride
REMOVE UM: CUSTOM
07/01/2018 multivitamins with fluoride,multivita min with fluoride
pediatric multivitamin no.16/sodium fluoride,pediatric multivitamins combination no.12/sodium fluoride
ADD TO FORMULARY Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 308 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
07/01/2018 multivitamins with fluoride,multivita min with fluoride
pediatric multivitamin no.16/sodium fluoride,pediatric multivitamins no.16 with sodium fluoride
ADD UM: QUANTITY 1 / 1 days
07/01/2018 multivitamins with fluoride,multivita min with fluoride
pediatric multivitamin no.16/sodium fluoride,pediatric multivitamins no.16 with sodium fluoride
ADD UM: AGE 0 to 12 yrs old
07/01/2018 multivitamins with fluoride,multivita min with fluoride
pediatric multivitamin no.16/sodium fluoride,pediatric multivitamins no.16 with sodium fluoride
REMOVE UM: CUSTOM
07/01/2018 multivitamins with fluoride,multivita min with fluoride,multi- vitamin with fluoride
pediatric multivitamins no.17 with sodium fluoride
ADD TO FORMULARY Non-Formulary Covered
07/01/2018 multivitamins with fluoride,multivita min with fluoride,multi- vitamin with fluoride
pediatric multivitamins no.17 with sodium fluoride
ADD UM: QUANTITY 1 / 1 days
07/01/2018 multivitamins with fluoride,multivita min with fluoride,multi- vitamin with fluoride
pediatric multivitamins no.17 with sodium fluoride
ADD UM: AGE 0 to 12 yrs old
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 309 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
07/01/2018 multivitamins with fluoride,multivita min with fluoride,multi- vitamin with fluoride
pediatric multivitamins no.17 with sodium fluoride
REMOVE UM: CUSTOM
07/01/2018 multivitamins with fluoride,multivita min and fluoride,multi- vitamin w- fluoride,multivita min with fluoride
pediatric multivitamin no.82 with sodium fluoride,pediatric multivitamin no.2/sodium fluoride,pediatric multivitamin no.150 with sodium fluoride
ADD TO FORMULARY Covered
07/01/2018 multivitamins with fluoride
pediatric multivitamin no.82 with sodium fluoride
ADD UM: QUANTITY 2 / 1 days
07/01/2018 multivitamins with fluoride
pediatric multivitamin no.82 with sodium fluoride
ADD UM: AGE 0 to 12 yrs old
07/01/2018 multivitamins with fluoride
pediatric multivitamin no.82 with sodium fluoride
REMOVE UM: CUSTOM Covered for CSHCS Only
07/01/2018 multivitamin with fluoride,multivita mins with fluoride
pediatric multivitamins no.17 with sodium fluoride,pediatric multivitamin no.16/sodium fluoride,multivitamins with fluoride,pediatric multivitamins combination no.12/sodium fluoride
CHANGE TIER Covered
07/01/2018 multivitamins with fluoride,multivita min with fluoride
pediatric multivitamin no.16/sodium fluoride,pediatric multivitamins no.16 with sodium fluoride
ADD UM: QUANTITY 1 / 1 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 310 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
07/01/2018 multivitamins with fluoride,multivita min with fluoride
pediatric multivitamin no.16/sodium fluoride,pediatric multivitamins no.16 with sodium fluoride
ADD UM: AGE 0 to 12 yrs old
07/01/2018 multivitamins with fluoride,multivita min with fluoride,multi- vitamin with fluoride
pediatric multivitamins no.17 with sodium fluoride
ADD UM: QUANTITY 1 / 1 days
07/01/2018 multivitamins with fluoride,multivita min with fluoride,multi- vitamin with fluoride
pediatric multivitamins no.17 with sodium fluoride
ADD UM: AGE 0 to 12 yrs old
07/01/2018 multivitamins with fluoride,polyvitam ins-fluoride,multi- vitamin w- fluoride,multivita min with fluoride
pediatric multivitamin no.2/sodium fluoride
ADD TO FORMULARY Covered
07/01/2018 multivitamins with fluoride,polyvitam ins-fluoride,multi- vitamin w- fluoride,multivita min with fluoride
pediatric multivitamin no.2/sodium fluoride
ADD UM: QUANTITY 2 / 1 days
07/01/2018 multivitamins with fluoride,polyvitam ins-fluoride,multi- vitamin w- fluoride,multivita min with fluoride
pediatric multivitamin no.2/sodium fluoride
ADD UM: AGE 0 to 12 yrs old
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 311 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
07/01/2018 multivitamins with fluoride,polyvitam ins-fluoride,multi- vitamin w- fluoride,multivita min with fluoride
pediatric multivitamin no.2/sodium fluoride
REMOVE UM: CUSTOM
07/01/2018 multivitamin and fluoride,multi- vitamin w- fluoride,multivita min with fluoride
pediatric multivitamin no.2/sodium fluoride
ADD UM: QUANTITY 2 / 1 days
07/01/2018 multivitamin and fluoride,multi- vitamin w- fluoride,multivita min with fluoride
pediatric multivitamin no.2/sodium fluoride
ADD UM: AGE 0 to 12 yrs old
07/01/2018 multivitamin and fluoride,multi- vitamin w- fluoride,multivita min with fluoride
pediatric multivitamin no.2/sodium fluoride
REMOVE UM: CUSTOM
07/01/2018 multivitamins with fluoride
pediatric multivitamin no.82 with sodium fluoride
ADD TO FORMULARY Non-Formulary Covered
07/01/2018 multivitamins with fluoride
pediatric multivitamin no.82 with sodium fluoride
ADD UM: QUANTITY 2 / 1 days
07/01/2018 multivitamins with fluoride
pediatric multivitamin no.82 with sodium fluoride
ADD UM: AGE 0 to 12 yrs old
07/01/2018 multivitamins with fluoride
pediatric multivitamin no.82 with sodium fluoride
REMOVE UM: CUSTOM Covered for CSHCS Only
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 312 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
07/01/2018 multivitamins w- fluoride- iron,multi-vitamin w-fluoride- iron,multi-vitamin- fluor- iron,multivitamin- iron-fluoride
pediatric multivitamin no.75/sodium fluoride/ferrous sulfate,pediatric multivitamin no.45/sodium fluoride/ferrous sulfate
ADD TO FORMULARY Covered
07/01/2018 multivitamins w- fluoride- iron,multi-vitamin w-fluoride- iron,multi-vitamin- fluor- iron,multivitamin- iron-fluoride
pediatric multivitamin no.45/sodium fluoride/ferrous sulfate
ADD UM: QUANTITY 2 / 1 days
07/01/2018 multivitamins w- fluoride- iron,multi-vitamin w-fluoride- iron,multi-vitamin- fluor- iron,multivitamin- iron-fluoride
pediatric multivitamin no.45/sodium fluoride/ferrous sulfate
ADD UM: AGE 0 to 12 yrs old
07/01/2018 multivitamins w- fluoride- iron,multi-vitamin w-fluoride- iron,multi-vitamin- fluor- iron,multivitamin- iron-fluoride
pediatric multivitamin no.45/sodium fluoride/ferrous sulfate
REMOVE UM: CUSTOM
07/01/2018 multivitamins w- fluoride-iron
pediatric multivitamin no.75/sodium fluoride/ferrous sulfate
ADD UM: QUANTITY 2 / 1 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 313 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
07/01/2018 multivitamins w- fluoride-iron
pediatric multivitamin no.75/sodium fluoride/ferrous sulfate
ADD UM: AGE 0 to 12 yrs old
07/01/2018 multivitamins w- fluoride-iron
pediatric multivitamin no.75/sodium fluoride/ferrous sulfate
REMOVE UM: CUSTOM Covered for CSHCS Only
07/01/2018 IDHIFA enasidenib mesylate ADD TO FORMULARY Covered 07/01/2018 IDHIFA enasidenib mesylate ADD UM: AUTHORIZATION PA applies 07/01/2018 IDHIFA enasidenib mesylate ADD TO FORMULARY Covered 07/01/2018 IDHIFA enasidenib mesylate ADD UM: AUTHORIZATION PA applies 07/01/2018 sudafed,nasal
decongestant,pse udoephedrine hcl,genaphed,wal - phed,sudogest,n asal & sinus decongestant,sup hedrine,suphedri n,suphedrine sinus congestion,medi- phedrine,decong estant,tylenol simply stuffy
pseudoephedrine hcl REMOVE UM: QUANTITY
07/01/2018 suphedrin pseudoephedrine hcl REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2018 suphedrine,suph edrine sinus congestion
pseudoephedrine hcl REMOVE FROM FORMULARY
Non-Formulary
07/01/2018 sudogest pseudoephedrine hcl REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 314 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
07/01/2018 pseudoephedrine hcl
pseudoephedrine hcl REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2018 nasal decongestant
pseudoephedrine hcl REMOVE FROM FORMULARY
Non-Formulary
07/01/2018 wal-phed pseudoephedrine hcl REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2018 nasal & sinus decongestant
pseudoephedrine hcl REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2018 pseudoephedrine hcl
pseudoephedrine hcl REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2018 pseudoephedrine hcl
pseudoephedrine hcl REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2018 HUMIRA PEN CROHN-UC-HS STARTER
adalimumab CHANGE UM: QUANTITY 4 / 28 days 6 / 28 days
07/01/2018 HUMIRA PEDIATRIC CROHN'S
adalimumab CHANGE UM: QUANTITY 4 / 28 days 6 / 28 days
07/01/2018 XATMEP methotrexate ADD TO FORMULARY Covered 07/01/2018 XATMEP methotrexate ADD UM: AUTHORIZATION PA applies 07/01/2018 FIRVANQ vancomycin hcl ADD TO FORMULARY Covered 07/01/2018 FIRVANQ vancomycin hcl ADD TO FORMULARY Covered 07/01/2018 HUMIRA
PEDIATRIC CROHN'S
adalimumab ADD TO FORMULARY Covered
07/01/2018 HUMIRA PEDIATRIC CROHN'S
adalimumab ADD UM: QUANTITY 6 / 28 days
07/01/2018 HUMIRA adalimumab ADD TO FORMULARY Covered 07/01/2018 HUMIRA adalimumab ADD UM: QUANTITY 4 / 28 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 315 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
07/01/2018 HUMIRA PEN adalimumab ADD TO FORMULARY Covered 07/01/2018 HUMIRA PEN adalimumab ADD UM: QUANTITY 4 / 28 days 07/01/2018 HUMIRA adalimumab ADD TO FORMULARY Covered 07/01/2018 HUMIRA adalimumab ADD UM: QUANTITY 2 / 28 days 07/01/2018 HUMIRA adalimumab ADD TO FORMULARY Covered 07/01/2018 HUMIRA adalimumab ADD UM: QUANTITY 2 / 28 days 07/01/2018 HUMIRA
PEDIATRIC CROHN'S
adalimumab ADD TO FORMULARY Covered
07/01/2018 HUMIRA PEDIATRIC CROHN'S
adalimumab ADD UM: QUANTITY 6 / 28 days
07/01/2018 HUMIRA adalimumab REMOVE UM: AUTHORIZATION
PA applies
07/01/2018 HUMIRA PEDIATRIC CROHN'S
adalimumab ADD UM: CUSTOM 1 fill per year
07/01/2018 ZADITOR ketotifen fumarate ADD TO FORMULARY Non-Formulary Covered 07/01/2018 ALAWAY ketotifen fumarate ADD TO FORMULARY Non-Formulary Covered 07/01/2018 HUMIRA
PEDIATRIC CROHN'S
adalimumab REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2018 HUMIRA PEN adalimumab REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2018 HUMIRA PEDIATRIC CROHN'S
adalimumab REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2018 HUMIRA adalimumab REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 316 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
07/01/2018 HUMIRA adalimumab REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2018 HUMIRA adalimumab REMOVE FROM FORMULARY
Covered Non-Formulary
07/01/2018 HUMIRA PEDIATRIC CROHN'S
adalimumab REMOVE UM: QUANTITY 6 / 28 days
07/01/2018 HUMIRA PEN adalimumab REMOVE UM: QUANTITY 4 / 28 days
07/01/2018 HUMIRA adalimumab REMOVE UM: QUANTITY 4 / 28 days
07/01/2018 HUMIRA adalimumab REMOVE UM: QUANTITY 2 / 28 days
07/01/2018 HUMIRA adalimumab REMOVE UM: QUANTITY 2 / 28 days
07/01/2018 HUMIRA PEDIATRIC CROHN'S
adalimumab REMOVE UM: QUANTITY 6 / 28 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 317 UPDATED 10/2018
August, 2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/01/2018 single use swab alcohol antiseptic pads ADD TO FORMULARY Non-Formulary Covered 08/01/2018 iv prep wipes,iv
antiseptic wipes alcohol antiseptic pads ADD TO FORMULARY Non-Formulary Covered
08/01/2018 alcohol prep pads,alcohol pads
alcohol antiseptic pads ADD TO FORMULARY Non-Formulary Covered
08/01/2018 ultilet alcohol swab
alcohol antiseptic pads ADD TO FORMULARY Non-Formulary Covered
08/01/2018 curity alcohol preps
alcohol antiseptic pads ADD TO FORMULARY Non-Formulary Covered
08/01/2018 alcohol prep swabs
alcohol antiseptic pads ADD TO FORMULARY Non-Formulary Covered
08/01/2018 alcohol swabs,alcohol swab
alcohol antiseptic pads ADD TO FORMULARY Non-Formulary Covered
08/01/2018 alcohol prep pads alcohol antiseptic pads ADD TO FORMULARY Non-Formulary Covered 08/01/2018 alcohol wipes alcohol antiseptic pads ADD TO FORMULARY Non-Formulary Covered 08/01/2018 webcol alcohol antiseptic pads ADD TO FORMULARY Non-Formulary Covered 08/01/2018 sure-prep alcohol
prep pads alcohol antiseptic pads ADD TO FORMULARY Non-Formulary Covered
08/01/2018 sure comfort alcohol
alcohol antiseptic pads ADD TO FORMULARY Non-Formulary Covered
08/01/2018 easy touch alcohol prep pads
alcohol antiseptic pads ADD TO FORMULARY Non-Formulary Covered
08/01/2018 incontrol alcohol pads
alcohol antiseptic pads ADD TO FORMULARY Non-Formulary Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 318 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
08/01/2018 pro comfort alcohol pads
alcohol antiseptic pads ADD TO FORMULARY Non-Formulary Covered
08/01/2018 caretouch alcohol prep pad
alcohol antiseptic pads ADD TO FORMULARY Non-Formulary Covered
08/01/2018 chemstrip k urine acetone test,strips ADD TO FORMULARY Non-Formulary Covered 08/01/2018 ketostix reagent urine acetone test,strips ADD TO FORMULARY Non-Formulary Covered 08/01/2018 ketone care test
strip urine acetone test,strips ADD TO FORMULARY Non-Formulary Covered
08/01/2018 trueplus ketone test strip
urine acetone test,strips ADD TO FORMULARY Non-Formulary Covered
08/01/2018 ketone test strip urine acetone test,strips ADD TO FORMULARY Non-Formulary Covered 08/28/2018 SYMTUZA darunavir
eth/cobicistat/emtricitabine/t enofovir alafenamide
ADD UM: CUSTOM Carve-out Bill MDHHS FFS
08/28/2018 BEBULIN VH IMMUNO,BEBUL IN,PROFILNINE SD,PROFILNINE ,KCENTRA
factor ix complex, prothrombin complex conc. (pcc) comb. 6,factor ix complex, prothrombin cplx conc(pcc) no.6, 3- factor,factor ix complex, prothrombin complex conc. (pcc) comb. 4,factor ix complex, prothrombin cplx conc(pcc) no.4, 3- factor,human prothrombin complex concentrate (pcc), 4-factor
ADD UM: CUSTOM Carve-out bill MDHHS FFS
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 319 UPDATED 10/2018
September, 2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/26/2018 magnesium
oxide,magnesium magnesium oxide CHANGE TIER Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 320 UPDATED 10/2018
October, 2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2018 doxycycline
hyclate doxycycline hyclate ADD TO FORMULARY Covered
10/01/2018 auvi- q,adrenaclick,epi nephrine
epinephrine CHANGE UM: QUANTITY 2 / 30 days 2 / 90 days
10/01/2018 auvi- q,epinephrine,epi pen,epipen 2- pak,adrenaclick
epinephrine CHANGE UM: QUANTITY 2 / 30 days 2 / 90 days
10/01/2018 wymzya fe norethindrone-ethinyl estradiol/ferrous fumarate
REMOVE FROM FORMULARY
Non-Formulary
10/01/2018 wymzya fe norethindrone-ethinyl estradiol/ferrous fumarate
REMOVE UM: GENDER
10/01/2018 zenchent fe norethindrone-ethinyl estradiol/ferrous fumarate
REMOVE FROM FORMULARY
Covered Non-Formulary
10/01/2018 zenchent fe norethindrone-ethinyl estradiol/ferrous fumarate
REMOVE UM: AUTHORIZATION
PA applies
10/01/2018 zeosa,femcon fe,zenchent fe,norethindrone- ethin estradiol,wymzya fe,norethin-eth estra-ferrous fum
norethindrone-ethinyl estradiol/ferrous fumarate
REMOVE UM: AUTHORIZATION
10/01/2018 norethindrone- ethin estradiol,norethin -eth estra-ferrous fum
norethindrone-ethinyl estradiol/ferrous fumarate
ADD TO FORMULARY Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 321 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value
10/01/2018 zeosa,femcon fe,zenchent fe,norethindrone- ethin estradiol,wymzya fe,norethin-eth estra-ferrous fum
norethindrone-ethinyl estradiol/ferrous fumarate
CHANGE UM: GENDER Female
10/01/2018 zeosa,femcon fe,zenchent fe,norethindrone- ethin estradiol,wymzya fe,norethin-eth estra-ferrous fum
norethindrone-ethinyl estradiol/ferrous fumarate
ADD UM: QUANTITY 84 / 84 days
10/01/2018 singulair,montelu kast sodium
montelukast sodium REMOVE UM: AGE
10/01/2018 singulair,montelu kast sodium
montelukast sodium REMOVE UM: AGE
10/01/2018 singulair,montelu kast sodium
montelukast sodium REMOVE UM: AGE
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 322 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2018 FLONASE
ALLERGY RELIEF
fluticasone propionate ADD TO FORMULARY Covered
10/01/2018 flonase allergy relief,fluticasone propionate,24 hour allergy relief,children's flonase allergy rlf,allergy relief,aller- flo,clarispray,chil dren 24 hr allergy relief,24 hour allergy
fluticasone propionate ADD UM: QUANTITY 0.533333333 / 1 days
10/01/2018 fluticasone propionate
fluticasone propionate CHANGE TIER Covered
10/01/2018 24 hour allergy relief,24 hour allergy
fluticasone propionate CHANGE TIER Covered
10/01/2018 CHILDREN'S FLONASE ALLERGY RLF
fluticasone propionate ADD TO FORMULARY Covered
10/01/2018 allergy relief fluticasone propionate CHANGE TIER Covered
10/01/2018 children 24 hr allergy relief
fluticasone propionate ADD TO FORMULARY Covered
10/01/2018 FLONASE fluticasone propionate ADD TO FORMULARY Non-Formulary Covered
10/01/2018 fluticasone propionate,flonas e
fluticasone propionate CHANGE UM: QUANTITY 0.056 / days 0.533333333 / 1 days
10/01/2018 ADMELOG insulin lispro ADD TO FORMULARY Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 323 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2018 HUMALOG,ADM
ELOG insulin lispro CHANGE UM: QUANTITY 60 / 30 days
10/01/2018 STEGLATRO ertugliflozin pidolate ADD TO FORMULARY Covered
10/01/2018 STEGLATRO ertugliflozin pidolate ADD TO FORMULARY Covered
10/01/2018 SEGLUROMET ertugliflozin pidolate/metformin hcl
ADD TO FORMULARY Covered
10/01/2018 SEGLUROMET ertugliflozin pidolate/metformin hcl
ADD TO FORMULARY Covered
10/01/2018 SEGLUROMET ertugliflozin pidolate/metformin hcl
ADD TO FORMULARY Covered
10/01/2018 SEGLUROMET ertugliflozin pidolate/metformin hcl
ADD TO FORMULARY Covered
10/01/2018 ZENPEP lipase/protease/amylase ADD TO FORMULARY Covered
10/01/2018 ZENPEP lipase/protease/amylase ADD UM: QUANTITY 720 / 30 days 10/01/2018 ZENPEP lipase/protease/amylase ADD TO FORMULARY Covered 10/01/2018 ZENPEP lipase/protease/amylase ADD UM: QUANTITY 720 / 30 days 10/01/2018 ZENPEP lipase/protease/amylase ADD TO FORMULARY Covered 10/01/2018 ZENPEP lipase/protease/amylase ADD UM: QUANTITY 720 / 30 days 10/01/2018 ZENPEP lipase/protease/amylase ADD TO FORMULARY Covered 10/01/2018 ZENPEP lipase/protease/amylase ADD UM: QUANTITY 480 / 30 days 10/01/2018 ZENPEP lipase/protease/amylase ADD TO FORMULARY Covered 10/01/2018 ZENPEP lipase/protease/amylase ADD UM: QUANTITY 480 / 30 days 10/01/2018 YONSA abiraterone acetate,
submicronized ADD TO FORMULARY Covered
10/01/2018 BRAFTOVI encorafenib ADD TO FORMULARY Covered
10/01/2018 BRAFTOVI encorafenib ADD TO FORMULARY Covered
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 324 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2018 np thyroid thyroid,pork ADD TO FORMULARY Covered
10/01/2018 armour thyroid,np thyroid,thyroid
thyroid,pork CHANGE UM: AGE 0 to 64 yrs old
10/01/2018 np thyroid thyroid,pork ADD TO FORMULARY Covered
10/01/2018 armour thyroid,thyroid,np thyroid
thyroid,pork,thyroid CHANGE UM: AGE 0 to 64 yrs old
10/01/2018 isotretinoin isotretinoin ADD TO FORMULARY Covered
10/01/2018 amnesteem,clara vis,absorica,zena tane,myorisan,sot ret,accutane,isotr etinoin
isotretinoin CHANGE UM: QUANTITY 2 / 1 days
10/01/2018 isotretinoin isotretinoin ADD TO FORMULARY Covered
10/01/2018 amnesteem,clara vis,absorica,sotre t,zenatane,myoris an,accutane,isotr etinoin
isotretinoin CHANGE UM: QUANTITY 2 / 1 days
10/01/2018 isotretinoin isotretinoin ADD TO FORMULARY Covered
10/01/2018 claravis,absorica, sotret,zenatane, myorisan,isotretin oin
isotretinoin CHANGE UM: QUANTITY 2 / 1 days
10/01/2018 isotretinoin isotretinoin ADD TO FORMULARY Covered
10/01/2018 amnesteem,clara vis,absorica,zena tane,myorisan,sot ret,accutane,isotr etinoin
isotretinoin CHANGE UM: QUANTITY 2 / 1 days
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 325 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2018 levalbuterol
tartrate hfa levalbuterol tartrate ADD TO FORMULARY Covered
10/01/2018 xopenex hfa,levalbuterol tartrate hfa
levalbuterol tartrate ADD UM: QUANTITY 15 / 25 days
10/01/2018 EPIPEN JR,EPIPEN JR 2- PAK,EPINEPHRI NE
epinephrine CHANGE UM: QUANTITY 2 / 90 days
10/01/2018 generess fe,layolis fe,norethin-eth estra-ferrous fum,kaitlib fe
norethindrone-ethinyl estradiol/ferrous fumarate
ADD UM: QUANTITY 84 / 84 days
10/01/2018 generess fe,layolis fe,norethin-eth estra-ferrous fum,kaitlib fe
norethindrone-ethinyl estradiol/ferrous fumarate
REMOVE UM: AUTHORIZATION
10/01/2018 armour thyroid,np thyroid,thyroid
thyroid,pork,thyroid CHANGE UM: AGE 0 to 64 yrs old
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 326 UPDATED 10/2018
November, 2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/01/2018 NOVOLOG insulin aspart REMOVE FROM
FORMULARY Covered Non-Formulary
11/01/2018 NOVOLOG insulin aspart REMOVE UM: QUANTITY 60 / 30 days
11/01/2018 APIDRA insulin glulisine REMOVE FROM FORMULARY
Covered Non-Formulary
11/01/2018 APIDRA insulin glulisine REMOVE UM: QUANTITY 2 / days
11/01/2018 HUMALOG insulin lispro REMOVE FROM FORMULARY
Covered Non-Formulary
11/01/2018 NOVOLOG insulin aspart REMOVE FROM FORMULARY
Covered Non-Formulary
11/01/2018 NOVOLOG insulin aspart REMOVE UM: QUANTITY 30 / 30 days
11/01/2018 HUMALOG insulin lispro REMOVE FROM FORMULARY
Covered Non-Formulary
11/01/2018 HUMALOG insulin lispro REMOVE UM: QUANTITY 30 / 30 days
11/01/2018 NOVOLOG FLEXPEN
insulin aspart REMOVE FROM FORMULARY
Covered Non-Formulary
11/01/2018 NOVOLOG FLEXPEN
insulin aspart REMOVE UM: QUANTITY 30 / 30 days
11/01/2018 APIDRA SOLOSTAR
insulin glulisine REMOVE FROM FORMULARY
Covered Non-Formulary
11/01/2018 APIDRA,APIDRA SOLOSTAR
insulin glulisine REMOVE UM: AGE 0 to 21 yrs old
11/01/2018 APIDRA,APIDRA SOLOSTAR
insulin glulisine REMOVE UM: QUANTITY 30 / 30 days
11/01/2018 HUMALOG KWIKPEN U-100
insulin lispro REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 327 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/01/2018 HUMALOG
JUNIOR KWIKPEN
insulin lispro REMOVE FROM FORMULARY
Covered Non-Formulary
11/01/2018 HUMALOG JUNIOR KWIKPEN
insulin lispro REMOVE UM: AGE Up to 21 yrs old
11/01/2018 HUMALOG JUNIOR KWIKPEN
insulin lispro REMOVE UM: QUANTITY 30 / 30 days
11/01/2018 ADMELOG SOLOSTAR
insulin lispro ADD TO FORMULARY Covered
11/01/2018 HUMALOG,HUM ALOG KWIKPEN U- 100,ADMELOG SOLOSTAR
insulin lispro CHANGE UM: QUANTITY 30 / 30 days
11/01/2018 HUMALOG,HUM ALOG KWIKPEN U- 100,ADMELOG SOLOSTAR
insulin lispro ADD UM: AGE 0 to 21 yrs old
11/01/2018 AEROSPAN flunisolide REMOVE FROM FORMULARY
Covered Non-Formulary
11/01/2018 AEROSPAN flunisolide REMOVE UM: QUANTITY 8.9 / 30 days
11/01/2018 FORADIL formoterol fumarate REMOVE FROM FORMULARY
Covered Non-Formulary
11/01/2018 FORADIL formoterol fumarate REMOVE UM: QUANTITY 2 / Day
11/01/2018 SYMBICORT budesonide/formoterol fumarate
REMOVE FROM FORMULARY
Covered Non-Formulary
11/01/2018 SYMBICORT budesonide/formoterol fumarate
REMOVE UM: QUANTITY 10.2 / 30 days
11/01/2018 SYMBICORT budesonide/formoterol fumarate
REMOVE FROM FORMULARY
Covered Non-Formulary
HAP/Midwest Health Plan, MI Medicaid Common Formulary Updates
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.PAGE 328 UPDATED 10/2018
Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/01/2018 SYMBICORT budesonide/formoterol
fumarate REMOVE UM: QUANTITY 10.2 / 30 days
11/01/2018 DULERA mometasone furoate/formoterol fumarate
REMOVE FROM FORMULARY
Covered Non-Formulary
11/01/2018 DULERA mometasone furoate/formoterol fumarate
REMOVE UM: QUANTITY 13 / 30 days
11/01/2018 DULERA mometasone furoate/formoterol fumarate
REMOVE FROM FORMULARY
Covered Non-Formulary
11/01/2018 DULERA mometasone furoate/formoterol fumarate
REMOVE UM: QUANTITY 13 / 30 days
11/01/2018 SYMBICORT budesonide/formoterol fumarate
ADD UM: QUANTITY 10.2 / 30 days
11/01/2018 SYMBICORT budesonide/formoterol fumarate
ADD UM: AGE 0 to 12 yrs old
11/01/2018 SYMBICORT budesonide/formoterol fumarate
ADD TO FORMULARY Non-Formulary
Covered
