docMcLaren Health Plan, MI Medicaid Common Formulary Updates
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McLaren Health Plan, MI Medicaid Common Formulary Updates
McLaren Health Plan, MI Medicaid Common Formulary Updates January, 2016 Effective Date Brand Name Generic Name varenicline tartrate Type of Change Previous Value CHANGE UM: CUSTOM New Value 01/01/2016 CHANTIX Max. 24 weeks therapy per year 01/01/2016 econazole nitrate econazole nitrate REMOVE UM: AUTHORIZATION 01/01/2016 econazole nitrate econazole nitrate ADD UM: QUANTITY 01/01/2016 zomig,zomig zolmitriptan zmt,zolmitriptan,z olmitriptan odt REMOVE UM: AUTHORIZATION 01/01/2016 adapalene adapalene REMOVE UM: AUTHORIZATION PA applies 01/01/2016 adapalene adapalene REMOVE UM: AUTHORIZATION PA applies 01/01/2016 ondansetron odt ondansetron 01/01/2016 granisetron hcl granisetron hcl 01/01/2016 malathion malathion 01/01/2016 rizatriptan rizatriptan benzoate CHANGE TIER Covered 01/01/2016 rizatriptan rizatriptan benzoate ADD UM: QUANTITY 9 / 30 days 01/01/2016 rizatriptan rizatriptan benzoate CHANGE TIER Covered 01/01/2016 rizatriptan rizatriptan benzoate ADD TO FORMULARY 01/01/2016 zomig,zomig zolmitriptan zmt,zolmitriptan,z olmitriptan odt 01/01/2016 PROTONIX pantoprazole sodium REMOVE UM: QUANTITY 1 / day 01/01/2016 PROTONIX pantoprazole sodium REMOVE UM: QUANTITY 2 / day PA applies 30 / 30 days CHANGE TIER Covered REMOVE UM: STEP ST applies REMOVE UM: AUTHORIZATION PA applies Non-Formulary Covered REMOVE UM: STEP BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 1 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2016 lansoprazole,prev lansoprazole acid REMOVE UM: AUTHORIZATION 01/01/2016 lansoprazole lansoprazole REMOVE UM: AUTHORIZATION 01/01/2016 oxybutynin chloride er oxybutynin chloride CHANGE TIER Covered 01/01/2016 oxybutynin chloride er oxybutynin chloride CHANGE TIER Covered 01/01/2016 DITROPAN XL oxybutynin chloride REMOVE UM: QUANTITY 01/01/2016 oxybutynin chloride er oxybutynin chloride CHANGE TIER 01/01/2016 DITROPAN XL oxybutynin chloride REMOVE UM: QUANTITY 2 / day 01/19/2016 DIFFERIN adapalene REMOVE UM: AUTHORIZATION PA applies 01/19/2016 adapalene,differi adapalene n REMOVE UM: AUTHORIZATION 01/19/2016 APIDRA,APIDRA insulin glulisine SOLOSTAR 01/20/2016 ampyra,4aminopyridine dalfampridine REMOVE UM: STEP PA applies 6 / day Covered ST applies REMOVE UM: AUTHORIZATION BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 2 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name 01/25/2016 pramipexole dihydrochloride,c aptopril,natural vegetable powder,albuterol sulfate,metamucil ,konsyl,parlodel,fi ber,bromocriptine mesylate,natural fiber laxative,mirapex, wal-mucil natural fiber lax,daily fiber 01/25/2016 acetaminophen,f acetaminophen,psyllium everall,children's husk (with sugar),estrogens, nonconjugated aspirin,children's fever reducer,konsyl,fib er,acephen,natur al fiber laxative,fever reducer,children's fever reducing,child pain rel-fever reducer,premarin pramipexole dihcl,captopril,psyllium husk (with sugar),albuterol sulfate,bromocriptine mesylate Type of Change Previous Value REMOVE UM: QUANTITY 36 / Day REMOVE UM: QUANTITY 33 / Day New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 3 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value 01/25/2016 carvedilol,lisinopri l,ibuprofen,propra nolol hcl,coreg,hydrom orphone hcl,dexamethaso ne,dilaudid,ibupro fen ib,budesonide,re paglinide,furosem ide,lysodren,pulm icort,prandin,zest ril,advil carvedilol,lisinopril,ibuprofen ,propranolol hcl,hydromorphone hcl,dexamethasone,budeso nide,repaglinide,furosemide, mitotane REMOVE UM: QUANTITY 32 / day 01/25/2016 nitrolingual,nitrogl nitroglycerin ycerin REMOVE UM: QUANTITY 0.245 / day 01/25/2016 sodium bicarbonate sodium bicarbonate REMOVE UM: QUANTITY 18.5 / Day 01/25/2016 calcium carbonate calcium carbonate REMOVE UM: QUANTITY 28 / Day 01/25/2016 propranolol hcl propranolol hcl REMOVE UM: QUANTITY 64 / day 01/25/2016 tums calcium ultra,ribavirin,reb carbonate,ribavirin,riociguat etol,antacid ultra strength,calcium carbonate,ultra strength antacid,calcium antacid,adempas, ribasphere REMOVE UM: QUANTITY 7 / Day 01/25/2016 methocarbamol,p methocarbamol,propranolol ropranolol hcl hcl,robaxin-750 REMOVE UM: QUANTITY 10.5 / day 01/25/2016 claravis REMOVE UM: QUANTITY 0.025 / day isotretinoin New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 4 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value REMOVE UM: QUANTITY 0.157 / day 01/25/2016 alendronate alendronate sodium sodium,fosamax 01/25/2016 children's pain & acetaminophen,azithromycin REMOVE UM: QUANTITY fever,children's tactinal,acetamin ophen,azithromyc in,children's acetaminophen,n onaspirin,children's nonaspirin,children's pain reliever,mapap,zit hromax 01/25/2016 prednisolone prednisolone sod phosphate sodium phosphate,orapre d REMOVE UM: QUANTITY 26.667 / day 01/25/2016 SYNAGIS palivizumab REMOVE UM: QUANTITY 0.15 / day 01/25/2016 PULMICORT FLEXHALER budesonide REMOVE UM: QUANTITY 0.267 / day New Value 50 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 5 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value 01/25/2016 tobramycindexamethasone, aimsco,ciprofloxa cin hcl,diclofenac sodium,fc2 female condom,ciloxan,t obradex,cromoly n sodium,kimono,d urex avanti bare,neomycinpolymyxingramicidin,neosp orin,kimono textured,kimono microthin,kimono microthin aqua lube,kimono maxx,trustex condom,trustexria,trustex latex condom,trustex,f antasy,condoms tobramycin/dexamethasone, condoms, latex, lubricated,ciprofloxacin hcl,diclofenac sodium,condoms, female,cromolyn sodium,condoms, latex, non-lubricated,neomycin sulfate/polymyxin b sulfate/gramicidin d REMOVE UM: QUANTITY 1.2 / Day 01/25/2016 PULMICORT FLEXHALER budesonide REMOVE UM: QUANTITY 0.067 / day 01/25/2016 HEMANGEOL propranolol hcl REMOVE UM: QUANTITY 149.533 / day 01/25/2016 sulfacetamide sodium,prednisol one acetate,pred forte,neomycinpolymyxindexameth,genta micin sulfate,bleph10,maxitrol,omnip red,garamycin sulfacetamide sodium,prednisolone acetate,neomycin/polymyxin b sulfate/dexamethasone,gent amicin sulfate REMOVE UM: QUANTITY 4.8 / day New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 6 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date 01/25/2016 Brand Name Generic Name fentanyl,duragesi fentanyl c Type of Change Previous Value REMOVE UM: QUANTITY 0.737 / day New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 7 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name 01/25/2016 hyoscyamine sulfate,clindamyci n hcl,sulfasalazine dr,amoxicillin,ace taminophen,com plete allergy,acetamino phencodeine,mycophe nolic acid,diltiazem hcl,ropinirole hcl,mycophenolat e mofetil,allergy,hy drocodoneacetaminophen,o xycodoneacetaminophen,al lergy relief,percocet,de smopressin acetate,predniso ne,sulfasalazine, cefdinir,propylthio uracil,allergy medicine,pain relief,tri-buffered aspirin,pain reliever,labetalol hcl,promethazine hcl,meperidine hcl,isosorbide dinitrate,cellcept, clonidine hcl,mapap,banop hen,diphenhydra mine hcl,buffered Generic Name Type of Change hyoscyamine REMOVE UM: QUANTITY sulfate,clindamycin hcl,sulfasalazine,amoxicillin, acetaminophen,diphenhydra mine hcl,acetaminophen with codeine phosphate,mycophenolate sodium,diltiazem hcl,ropinirole hcl,mycophenolate mofetil,hydrocodone bitartrate/acetaminophen,ox ycodone hcl/acetaminophen,desmopr essin acetate,prednisone,cefdinir, propylthiouracil,aspirin/calci um carbonate/magnesium,labet alol hcl,promethazine hcl,meperidine hcl,isosorbide dinitrate,clonidine hcl,pentazocine hcl/naloxone hcl,nimodipine,nifedipine,hy dralazine hcl,acarbose,albuterol sulfate,acetazolamide,methi mazole,leucovorin calcium,methyldopa,potassi um chloride,midodrine hcl,cinacalcet hcl,dronabinol,dapsone,met hazolamide,potassium citrate,verapamil hcl,estropipate,timolol maleate,pindolol,quinidine sulfate,thyroid,pork,methado Previous Value New Value 12 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 8 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name aspirin,pentazoci ne-naloxone hcl,cardizem,aller gy medication,nimod ipine,sulfazine,nif edipine,hydralazi ne hcl,acarbose,nule v,levsinsl,levsin,albuterol sulfate,acetazola mide,valu-dryl allergy medicine,antihist amine,edspaz,methimazol e,leucovorin calcium,methyldo pa,athenol,diphe dryl,klor-con 8,anaspaz,potass ium chloride,tapazole, midodrine hcl,non-aspirin pain relief,endocet,sen sipar,feverall,lorc et plus,dronabinol,n onaspirin,requip,da psone,norco,waldryl,wal-dryl allergy,nighttime allergy relief,allergtime,methazolami ne hcl,codeine sulfate,morphine sulfate,estrogens,esterified, dexamethasone Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 9 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value de,cleocin hcl,potassium citrate er,neptazane,ben adryl allergy,benadryl,b ufferin,procardia, phenadoz,total allergy,azulfidine, diphenhist,aspirin buffered,tylenol,p romethegan,geridryl,acephen,lorc et hd,lorcet,phenerg an,verapamil hcl,estropipate,ktab er,lortab,precose, demerol,urocitk,tactinal,timolol maleate,pindolol, catapres,vicks qlearquil nighttime,symax, symaxsl,masophen,quin idine sulfate,naturethroid,myfortic,ale rcaps,marinol,wes throid,hyosyne,al ertab,pharbetol,dda vp,pharbedryl,qdryl,qpap,methadone hcl,methadose,m BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 10 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value REMOVE UM: QUANTITY 0.042 / day New Value edi-tabs,codeine sulfate,trandate, morphine sulfate,tylenolcodeine no.3,mediphedryl,roxicet,os cimin,menest,dex amethasone,dolo phine hcl,pain & fever,methadone intensol,oscimin sl 01/25/2016 EPOGEN,PROC epoetin alfa RIT BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 11 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change 01/25/2016 torsemide,nicotin e lozenge,carbinox amine maleate,arbinoxa ,acyclovir,bethan echol chloride,prazosin hcl,cefadroxil,me gestrol acetate,fluconazo le,cefaclor,terazo sin hcl,oxybutynin chloride,palgic,ra nitidine hcl,cefprozil,bum etanide,zovirax,ni corette,demadex, diflucan,ferrous sulfate,stop smoking aid,quit 4,quit 2,minipress,urech oline,megace torsemide,nicotine REMOVE UM: QUANTITY polacrilex,carbinoxamine maleate,acyclovir,bethanech ol chloride,prazosin hcl,cefadroxil,megestrol acetate,fluconazole,cefaclor, terazosin hcl,oxybutynin chloride,ranitidine hcl,cefprozil,bumetanide,ferr ous sulfate 20 / Day 01/25/2016 metoprolol tartrate,pramipex ole dihydrochloride,c alcium,theophylli ne anhydrous,calciu m carbonate,mirape x,captopril,high potency calcium,super calcium,lopressor ,theochron metoprolol tartrate,pramipexole dihcl,calcium carbonate,theophylline anhydrous,captopril 4.5 / Day REMOVE UM: QUANTITY Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 12 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value 01/25/2016 oyster shell calcium carbonate calcium,calcium,c alcium carbonate,natural calcium,oysco500 REMOVE UM: QUANTITY 5.5 / Day 01/25/2016 hydroxyzine hcl hydroxyzine hcl REMOVE UM: QUANTITY 200 / day 01/25/2016 PEDIAVANCE sodium/potassium/chloride salt/zinc/dextrose/fructose REMOVE UM: QUANTITY 320 / day 01/25/2016 fluticasone fluticasone propionate propionate,flonas e allergy relief REMOVE UM: QUANTITY 1.053 / day 01/25/2016 aspirin,aspirin ec,ipratropiumalbuterol,metopro lol tartrate,tizanidine hcl,aspirtrin,pramipexole dihydrochloride,p otassium chloride,ecotrin,c aptopril,bromocri ptine mesylate,lite coat aspirin,mirapex,e cpirin,quinidine sulfate,klor-con sprinkle,parlodel, duoneb REMOVE UM: QUANTITY 18 / day 01/25/2016 cholestyramine,q cholestyramine (with sugar) uestran REMOVE UM: QUANTITY 54 / day aspirin,ipratropium bromide/albuterol sulfate,metoprolol tartrate,tizanidine hcl,pramipexole dihcl,potassium chloride,captopril,bromocript ine mesylate,quinidine sulfate New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 13 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value 01/25/2016 tacrolimus,polytri tacrolimus,polymyxin b m,polymyxin b sulfate/trimethoprim,apraclo sulnidine hcl trimethoprim,prog raf,iopidine,apracl onidine hcl,hecoria REMOVE UM: QUANTITY 0.6 / day 01/25/2016 isoniazid isoniazid REMOVE UM: QUANTITY 42.57 / day 01/25/2016 ARANESP,HUMI RA PEN,AVONEX,H UMIRA,HUMIRA PEN CROHNUC-HS STARTER,HUMI RA PEDIATRIC CROHN'S,HUMI RA PEN PSORIASISUVEITIS darbepoetin alfa in polysorbate 80,adalimumab,interferon beta-1a/albumin human REMOVE UM: QUANTITY 0.147 / day 01/25/2016 albuterol sulfate,accuneb albuterol sulfate REMOVE UM: QUANTITY 72 / day 01/25/2016 albuterol sulfate,accuneb albuterol sulfate REMOVE UM: QUANTITY 142.857 / day 01/25/2016 morphine sulfate morphine sulfate REMOVE UM: QUANTITY 45 / day 01/25/2016 amoxicillin,lactulo amoxicillin,lactulose,dexame REMOVE UM: QUANTITY se,dexamethason thasone e,constulose 01/25/2016 fluticasone fluticasone propionate propionate,flonas e REMOVE UM: QUANTITY New Value 240 / Day 1.067 / day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 14 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value 01/25/2016 nicotine gum,amoxicillin,cl indamycin hcl,ropinirole hcl,clonidine hcl,prednisone,la betalol hcl,oxycodone hcl,dronabinol,iso sorbide dinitrate,roxicodo ne,demerol,cefdi nir,isordil titradose,ethamb utol hcl,meperidine hcl,nicorette,cata pres,neomycin sulfate,marinol,qu it 4,premarin,requip ,nicorelief,cleocin hcl,trandate,codei ne sulfate,menest,de xamethasone nicotine polacrilex,amoxicillin,clinda mycin hcl,ropinirole hcl,clonidine hcl,prednisone,labetalol hcl,oxycodone hcl,dronabinol,isosorbide dinitrate,meperidine hcl,cefdinir,ethambutol hcl,neomycin sulfate,estrogens, conjugated,codeine sulfate,estrogens,esterified, dexamethasone REMOVE UM: QUANTITY 24 / day 01/25/2016 FORTEO teriparatide REMOVE UM: QUANTITY 0.08 / day New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 15 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change 01/25/2016 estradiol,methylpr ednisolone,potas sium chloride,prochlor perazine maleate,medrol,a dempas,ciproflox acin,ciprofloxacin hcl,cipro,enemee z,estrace,compaz ine,klor-con sprinkle estradiol,methylprednisolone REMOVE UM: QUANTITY ,potassium chloride,prochlorperazine maleate,riociguat,ciprofloxac in,ciprofloxacin hcl,docusate sodium/benzocaine 15 / Day 01/25/2016 amoxicillin amoxicillin REMOVE UM: QUANTITY 6.5 / day 01/25/2016 HUMIRA adalimumab REMOVE UM: QUANTITY 0.294 / day 01/25/2016 ENBREL etanercept REMOVE UM: QUANTITY 0.305 / day 01/25/2016 aspirin ec,adult aspirin low dose aspirin ec,aspirin,childre n's aspirin,aspirlow,low dose aspirin ec,ecotrin,lo-dose aspirin ec,miniprin,aspir 81,st. joseph aspirin,bayer chewable aspirin REMOVE UM: QUANTITY 74 / day 01/25/2016 NUVARING 01/25/2016 vandazole,metro metronidazole nidazole,metrogel -vaginal etonogestrel/ethinyl estradiol REMOVE UM: QUANTITY REMOVE UM: QUANTITY Previous Value New Value 0.055 / day 14 / day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 16 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name 01/25/2016 ramipril,quinapril hcl,carvedilol,glyc opyrrolate,carbid opalevodopa,acetami nophen extra strength,valacycl ovir,cephalexin,lo peramide,acetam inophen,ibuprofe n,acid reducer,sucralfat e,metoclopramid e hcl,pain reliever,spironola ctone,allopurinol, glipizidemetformin,isosor bide mononitrate er,tramadol hcl,pain relief,metronidaz ole,metoprolol succinate,enalapr il maleate,dilaudid, glyburidemetformin hcl,baclofen,hydr oxyzine hcl,glipizide,propr anolol hcl,lovastatin,met hylergonovine maleate,antidiarrheal,hydroch lorothiazide,indo methacin,sulfame thoxazole- Generic Name Type of Change ramipril,quinapril REMOVE UM: QUANTITY hcl,carvedilol,glycopyrrolate, carbidopa/levodopa,acetami nophen,valacyclovir hcl,cephalexin,loperamide hcl,ibuprofen,famotidine,cim etidine,sucralfate,metoclopr amide hcl,spironolactone,allopurino l,glipizide/metformin hcl,isosorbide mononitrate,tramadol hcl,metronidazole,metoprolo l succinate,enalapril maleate,hydromorphone hcl,glyburide/metformin hcl,baclofen,hydroxyzine hcl,glipizide,propranolol hcl,lovastatin,methylergonov ine maleate,hydrochlorothiazide ,indomethacin,sulfamethoxa zole/trimethoprim,simvastati n,pseudoephedrine hcl,celecoxib,glimepiride,riva stigmine tartrate,nadolol,dicyclomine hcl,diclofenac sodium,glyburide,furosemid e,budesonide,levothyroxine sodium,cyclobenzaprine hcl,pravastatin sodium,tetracycline hcl,doxazosin mesylate,flavoxate hcl,sodium fluoride,felodipine,lisinopril, meclizine hcl,diphenoxylate hcl/atropine Previous Value New Value 8 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 17 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name trimethoprim,simv astatin,nasal decongestant,cel ecoxib,glimepirid e,famotidine,rivas tigmine,nadolol,s uphedrine,dicyclo mine hcl,diclofenac sodium,carafate, bentyl,glyburide,f urosemide,budes onide,levothyroxi ne sodium,cycloben zaprine hcl,pravastatin sodium,pepcid ac,tetracycline hcl,doxazosin mesylate,flavoxat e hcl,fluoritab,felodi pine er,imdur,lisinopril, meclizine hcl,prinivil,diphen oxylateatropine,cyprohe ptadine hcl,pseudoephed rine hcl,zocor,heartbu rn prevention,hydro xyzine pamoate,pharbet ol,carbidopalevodopa sulfate,cyproheptadine hcl,hydroxyzine pamoate,nitrofurantoin macrocrystal,fosinopril sodium,trandolapril,albuterol sulfate,azithromycin,famcicl ovir,benazepril hcl,ropinirole hcl,alendronate sodium,fluconazole,rifampin, clonidine hcl,atorvastatin calcium,glyburide,micronize d,misoprostol,antipyrine/ben zocaine,labetalol hcl,nystatin,tinidazole,repagl inide,penicillin v potassium,chlorthalidone,me tolazone,flecainide acetate,spironolactone/hydr ochlorothiazide,disopyramid e phosphate,dicloxacillin sodium,mexiletine hcl,valsartan,ampicillin trihydrate,pyrazinamide,dipy ridamole,chlorothiazide,beth anechol chloride,erythromycin base,perindopril erbumine,itraconazole,dana zol,cefpodoxime proxetil,multivit with min/iron picolinate/fa/calcium/d3/ami no acid,mesalamine,cromolyn sodium,tobramycin,everolim us Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 18 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value er,hydromorphon e hcl,nitrofurantoin, fosinopril sodium,acetamin ophen es,zestril,nonaspirin extra strength,trandola pril,albuterol sulfate,sinemet cr,sinemet 10100,sinemet 25250,sinemet 25100,keflex,azithro mycin,suphedrine sinus congestion,famci clovir,levoxyl,corg ard,benazepril hcl,glipizide er,non-aspirin pain relief,coreg,acid relief,requip,alen dronate sodium,fluconazo le,rifampin,clonidi ne hcl,atorvastatin calcium,glynase, misoprostol,ropini role hcl,pain relief extra strength,fluoride, sodium fluoride,antipyrine benzocaine,suph BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 19 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value edrin,mapap,labe talol hcl,nystatin,tinida zole,repaglinide,a cid controller,penicilli nv potassium,chlorth alidone,metolazo ne,flecainide acetate,spironola ctonehctz,heartburn relief,disopyramid e phosphate,diclox acillin sodium,cimetidin e,mexiletine hcl,valsartan,lom otil,glyburide micronized,cytote c,aldactone,aldac tazide,glipizide xl,ampicillin trihydrate,celebre x,flagyl,norpace,p yrazinamide,tacti nal,zithromax,lasi x,persantine,diab eta,catapres,ama ryl,tylenol extra strength,chlorothi azide,aurodex,be thanechol chloride,glucotrol xl,glucotrol,cardur a,diflucan,erythro mycin,antivert,per BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 20 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value indopril erbumine,q-pap extra strength,bactrim,t ambocor,meditabs,medi-tabs extra strength,robinul,d ipyridamole,walphed,auroguard,l udent fluoride,altace,me di-phedrine,otic care,zaroxolyn,sh ake that ache,itraconazole ,unithroid,danazol ,cefpodoxime proxetil,k-pax immune support,sudogest ,reglan,prandin,n asal & sinus decongestant,tag amet hb,rifadin,urecholi ne,mavik,tylophe n,masophen,tind amax,parcopa,lipi tor,vistaril,valtrex, accupril,pentasa, macrodantin,synt hroid,cromolyn sodium,microzide ,diovan,famvir,ex elon,tobi podhaler,pulmico rt,toprol xl,vasotec,extra BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 21 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value strength nonaspirin,ultram,tra ndate,zyloprim,afi nitor,sporanox,pa in & fever,lotensin 01/25/2016 zolmitriptan,narat riptan hcl,sumatriptan succinate,rizatript an,imitrex,zolmitri ptan odt,naratriptan zolmitriptan,naratriptan hcl,sumatriptan succinate,rizatriptan benzoate REMOVE UM: QUANTITY 9 / 30 days 01/25/2016 ciclodan ciclopirox REMOVE UM: QUANTITY 6.6 / 28 days 01/25/2016 lice treatment,nix,per methrin,hyoscya mine sulfate,lice cream rinse,clarithromyc in,lindane,lice killing,phoslyra,sf rowasa,estradiol, cefaclor,linezolid, hyosyne,estrace, mesalamine,meth adone hcl,clemastine fumarate,zyvox permethrin,hyoscyamine REMOVE UM: QUANTITY sulfate,clarithromycin,lindan e,calcium acetate,mesalamine,estradi ol,cefaclor,linezolid,methado ne hcl,clemastine fumarate 60 / Day 01/25/2016 amoxicillin amoxicillin 150 / day REMOVE UM: QUANTITY BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 22 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value 01/25/2016 metformin hcl,naproxen sodium,acyclovir, potassium chloride,cimetidin e,flanax,acitretin,f luconazole,morph ine sulfate er,ibuprofen,dipyr idamole,all day pain relief,klorcon m20,warfarin sodium,jantoven, all day relief,walproxen,adempas, ms contin,coumadin, mefloquine hcl,clindamycin phosphate,aleve, norpace,bumetan ide,zovirax,tamifl u,persantine,jakaf i,clotrimazole,dis opyramide phosphate,klorcon,fenoprofen calcium,glucopha ge,mediproxen,di flucan,cleocin,pul mozyme,revlimid, fem-cal citrate,soriatane, midol metformin hcl,naproxen REMOVE UM: QUANTITY sodium,acyclovir,potassium chloride,cimetidine,acitretin,f luconazole,morphine sulfate,ibuprofen,dipyridamo le,warfarin sodium,riociguat,mefloquine hcl,clindamycin phosphate,disopyramide phosphate,bumetanide,oselt amivir phosphate,ruxolitinib phosphate,clotrimazole,feno profen calcium,dornase alfa,lenalidomide,calcium citrate/magnesium ox/vit d2/manganese/boron/silica 5 / Day 01/25/2016 amoxicillin amoxicillin REMOVE UM: QUANTITY 75 / day 01/25/2016 propafenone hcl,rythmol propafenone hcl REMOVE UM: QUANTITY 4.613 / day New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 23 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value 01/25/2016 AVONEX,AVON interferon beta-1a EX PEN REMOVE UM: QUANTITY 0.036 / day 01/25/2016 ofloxacin,ocuflox ofloxacin REMOVE UM: QUANTITY 2.4 / day 01/25/2016 calcium gluconate calcium gluconate REMOVE UM: QUANTITY 62 / Day 01/25/2016 PEGASYS PROCLICK peginterferon alfa-2a REMOVE UM: QUANTITY 0.098 / day 01/25/2016 PEGASYS peginterferon alfaPROCLICK,AVO 2a,interferon beta-1a NEX REMOVE UM: QUANTITY 0.074 / day 01/25/2016 nicotine gum,hydralazine hcl,amoxicillinclavulanate potass,estradiol,s enna,augmentin, ondansetron hcl,prochlorperazi ne maleate,paroex,c hlorhexidine gluconate,nicorett e,periogard,clarit hromycin,cefaclor ,nicorelief,quit 2,colestid,methad one hcl,estrace,comp azine,peridex,zofr an,colestipol hcl,biaxin REMOVE UM: QUANTITY 30 / Day 01/25/2016 mercaptopurine,p mercaptopurine urinethol REMOVE UM: QUANTITY 0.05 / day nicotine polacrilex,hydralazine hcl,amoxicillin/potassium clavulanate,estradiol,senna leaf extract,ondansetron hcl,prochlorperazine maleate,chlorhexidine gluconate,clarithromycin,cef aclor,colestipol hcl,methadone hcl New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 24 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value 01/25/2016 cabergoline,simv astatin,unithroid,p aricalcitol,levothy roxine sodium,caffeine citrate,cafcit,zoco r,armour thyroid,synthroid, zemplar cabergoline,simvastatin,levo thyroxine sodium,paricalcitol,caffeine citrated,thyroid,pork REMOVE UM: QUANTITY 0.5 / Day 01/25/2016 fluorometholone, fluorometholone,ketorolac ketorolac tromethamine,fondaparinux tromethamine,ari sodium,atropine sulfate xtra,atropine sulfate,fondapari nux sodium,acular,iso pto atropine,atropine care,fml forte,fml REMOVE UM: QUANTITY 0.8 / day 01/25/2016 ropinirole hcl,requip REMOVE UM: QUANTITY 96 / day ropinirole hcl New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 25 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value 01/25/2016 acyclovir,torsemi de,klor-con m10,potassium chloride,prazosin hcl,klor-con 10,multidelyn,warfarin sodium,bumetani de,calcium carbonate,terazo sin hcl,jantoven,mino xidil,tobramycin,z ovirax,erythromyc in ethylsuccinate,co umadin,e.e.s. 400,ipratropium bromide,k-tab er,cetirizine hcl,jakafi,minipre ss,demadex,afinit or disperz,mepron,a tovaquone,tobi,m y favorite multiple acyclovir,torsemide,potassiu m chloride,prazosin hcl,multivitamin,warfarin sodium,bumetanide,calcium carbonate,terazosin hcl,minoxidil,tobramycin in 0.225 % sodium chloride,erythromycin ethylsuccinate,ipratropium bromide,cetirizine hcl,ruxolitinib phosphate,everolimus,atova quone REMOVE UM: QUANTITY 10 / Day 01/25/2016 calcitonincalcitonin,salmon,synthetic salmon,fortical,mi acalcin REMOVE UM: QUANTITY 0.124 / day 01/25/2016 PROCRIT,EPOG epoetin alfa EN REMOVE UM: QUANTITY 0.021 / day 01/25/2016 SYMBICORT REMOVE UM: QUANTITY 0.46 / day budesonide/formoterol fumarate New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 26 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name 01/25/2016 amantadine,torse mide,megestrol acetate,cefprozil, epaned,clearlax,i nfant's pain reliever,bethanec hol chloride,nystatin, hydroxyzine hcl,acetaminophe n,laxative peg 3350,penicillin v potassium,infant' s pain relief,laxa clear,silapap,min oxidil,polyethylen e glycol 3350,infant's nonaspirin,cefadroxil, q-pap,infant's acetaminophen,n aproxen,griseoful vin,diuril,mapap infant,naprosyn, miralax,cefpodoxi me proxetil,infants' pain reliever,smoothla x,glycolax,demad ex,powderlax,infa nts pain reliever,gavilax,n ortemp,children's nonaspirin,gentlelax, medi-tabs pain reliever,peg3350, purelax,urecholin Generic Name Type of Change amantadine REMOVE UM: QUANTITY hcl,torsemide,megestrol acetate,cefprozil,enalapril maleate,polyethylene glycol 3350,acetaminophen,bethan echol chloride,nystatin,hydroxyzin e hcl,penicillin v potassium,minoxidil,cefadro xil,naproxen,griseofulvin, microsize,chlorothiazide,cef podoxime proxetil,pseudoephedrine hcl,diphenoxylate hcl/atropine sulfate Previous Value New Value 40 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 27 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value desmopressin acetate,betaxolol hcl,flurbiprofen sodium,desmopressin acetate (nonrefrigerated),budesonide/for moterol fumarate REMOVE UM: QUANTITY 0.4 / day New Value e,nasal decon (pseudoephedrin e),pseudoephedri ne hcl,diphenoxylate -atropine 01/25/2016 desmopressin acetate,betaxolol hcl,flurbiprofen sodium,ddavp,sy mbicort,stimate,o cufen 01/25/2016 cholestyramine cholestyramine/aspartame light,prevalite,que stran light REMOVE UM: QUANTITY 34.2 / day 01/25/2016 HUMIRA adalimumab REMOVE UM: QUANTITY 0.588 / day 01/25/2016 pramipexole dihydrochloride,ti zanidine hcl,morphine sulfate,metoprolol tartrate,theophylli ne anhydrous,zanafl ex,balsalazide disodium,captopri l,mirapex,magne bind 400 rx,colazal,lopress or,theochron pramipexole di-hcl,tizanidine REMOVE UM: QUANTITY hcl,morphine sulfate,metoprolol tartrate,theophylline anhydrous,balsalazide disodium,captopril,calcium carbonate/magnesium carbonate/folic acid 01/25/2016 EPOGEN,PROC epoetin alfa RIT REMOVE UM: QUANTITY 9 / Day 0.105 / day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 28 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name 01/25/2016 metformin hcl,multivitamins with minerals,ferrous sulfate,pioglitazo ne hcl,fenofibrate,a moxicillinclavulanate potass,mondoxyn e nl,clarithromycin,i ron,ondansetron odt,oxybutynin chloride er,calciummagnesiumzinc,pentoxifylline ,amiodarone hcl,ondansetron hcl,augmentin,ac etic acid,iron supplement,hair, skin and nails,ursodiol,dilti azem er,jantoven,terbut aline sulfate,lidocaine,li doderm,naproxen ,warfarin sodium,icaps plus,sildenafil,riza triptan,cal mag zinc + d,coumadin,nate glinide,cal mag zinc + d3,ciprofloxacin Generic Name Type of Change metformin hcl,multivitamin REMOVE UM: QUANTITY with minerals,ferrous sulfate,pioglitazone hcl,fenofibrate nanocrystallized,amoxicillin/ potassium clavulanate,doxycycline monohydrate,clarithromycin, ondansetron,oxybutynin chloride,calcium/magnesium /zinc,pentoxifylline,amiodaro ne hcl,ondansetron hcl,acetic acid,ursodiol,diltiazem hcl,warfarin sodium,terbutaline sulfate,lidocaine,naproxen,si ldenafil citrate,rizatriptan benzoate,calcium carbonate/vitamin d3/magnesium oxide/zinc oxide,nateglinide,ciprofloxac in hcl,levofloxacin,multivit, ca, minerals/ferrous gluconate/folic acid/biotin,lansoprazole,cefa clor,promethazine hcl,propranolol hcl,midodrine hcl,multivitamin with minerals/folic acid/biotin,griseofulvin ultramicrosize,lamivudine,no rethindrone acetate,clemastine fumarate,chloroquine phosphate,oseltamivir phosphate,enoxaparin sodium,pramipexole di- Previous Value New Value 3 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 29 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name hcl,levofloxacin,la nsoprazole,cefacl or,promethazine hcl,daily vitamin formulaminerals,propran olol hcl er,midodrine hcl,mega multivitamin with mineral,grispeg,one daily energy,lamivudin e hbv,norethindron e acetate,diltiazem hcl,clemastine fumarate,chloroq uine phosphate,tamiflu ,enoxaparin sodium,pramipex ole dihydrochloride,b udesonide ec,ecnaprosyn,theoph ylline anhydrous,multipl e vitamin,maxalt,on e-a-day maximum formula,mega multi w-chelated minerals,hydralaz ine hcl,acarbose,nitro - hcl,budesonide,theophylline anhydrous,hydralazine hcl,acarbose,nitroglycerin,fe nofibric acid (choline),phenazopyridine hcl,pyrimethamine,calcium carbonate/vit d3/magnesium ox & stearate/zinc sulf,fludrocortisone acetate,acebutolol hcl,multivitamin with iron,other minerals/folic acid/biotin,dapsone,methyld opa/hydrochlorothiazide,tim olol maleate,estropipate,multivits , ca, minerals/iron fumarate/folic acid,multivitamin with calcium, minerals/folic acid,isosorbide dinitrate,thyroid,pork,aztreon am lysine,riociguat,ruxolitinib phosphate,chlorpropamide, methadone hcl,rivaroxaban,canagliflozin ,pentosan polysulfate sodium Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 30 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value dur,monodox,fen ofibric acid,diltiazem 24hr er,cardizem la,diltiazem 24hr cd,phenazopyridi ne hcl,daraprim,gluc ophage,nitroglyce rin patch,doxycycline monohydrate,calc ium-magnesiumzinc-vit d,fludrocortisone acetate,sectral,ac ebutolol hcl,griseofulvin ultramicrosize,da psone,cordarone, tab-a-viteminerals,methyld opahydrochlorothiazi de,theochron,tim olol maleate,ogen,tiaz ac,ultra freeda,revatio,iso chron,armour thyroid,np thyroid,aygestin,p romethegan,pace rone,biaxin,phen ergan,estropipate ,isosorbide dinitrate,precose, cipro,cayston,ade mpas,lamivudine, BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 31 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value REMOVE UM: QUANTITY 0.21 / day New Value pyridium,nitrostat, actigall,matzim la,ferrousul,jakafi, trental,chlorpropa mide,taztia xt,ferosul,epivir hbv,tricor,mirape x,zofran odt,diltia xt,zofran,feosol,c ardizem cd,inderal la,cartia xt,lovenox,nature -throid,one daily complete,westhro id,actos,one daily plus minerals,starlix,dil t-cd,dilt-xr,men's one daily,cardizem,trili pix,methadone hcl,minitran,ditrop an xl,methadose,bee zee,levaquin,ento cort ec,xarelto,diltzac er,ferrotime,invokana,el miron,diskets,anti oxidant vitamin 01/25/2016 PROCRIT,EPOG epoetin alfa EN BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 32 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name 01/25/2016 gavilyte-n,colyte with flavor packets,peg 3350electrolyte,peg3350 and electrolytes,peg3350 with flavor packs,nulytely with flavor packs,golytely,tril yte with flavor packets,gavilytec,gavilyte-g Generic Name sodium chloride/sodium bicarbonate/potassium chloride/peg,peg 3350/sod sulf/sod bicarbonate/sod chloride/potassium chl Type of Change Previous Value REMOVE UM: QUANTITY 4080 / Day New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 33 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name 01/25/2016 clarithromycin,clin damycin hcl,ascomp with codeine,butalbcaffacetaminophcodein,ropinirole hcl,mondoxyne nl,diltiazem hcl,calcium citrate - vitamin d,butalbitalacetaminophencaffe,butalbitalaspirincaffeine,oxybutyn in chloride er,lansoprazole,ri zatriptan,ondans etron hcl,mycophenolat e mofetil,terbutaline sulfate,laxative,b utalbital compoundcodeine,pilocarpi ne hcl,ondansetron odt,acetaminoph encodeine,predniso ne,desmopressin acetate,acetazola mide,ms contin,tencon,nat eglinide,salagen, women's gentle laxative,cefaclor, Generic Name Type of Change clarithromycin,clindamycin REMOVE UM: QUANTITY hcl,codeine phosphate/butalbital/aspirin/ caffeine,butalbital/acetamino phen/caffeine/codeine phosphate,ropinirole hcl,doxycycline monohydrate,diltiazem hcl,calcium citrate/cholecalciferol (vitamin d3),butalbital/acetaminophe n/caffeine,butalbital/aspirin/c affeine,oxybutynin chloride,lansoprazole,rizatrip tan benzoate,ondansetron hcl,mycophenolate mofetil,terbutaline sulfate,bisacodyl,pilocarpine hcl,ondansetron,acetaminop hen with codeine phosphate,prednisone,desm opressin acetate,acetazolamide,morp hine sulfate,butalbital/acetaminop hen,nateglinide,cefaclor,eth ambutol hcl,promethazine hcl,ketoprofen,methimazole, ciprofloxacin hcl,griseofulvin ultramicrosize,ribavirin,isoso rbide dinitrate,pramipexole di-hcl,midodrine hcl,clemastine fumarate,diphenhydramine hcl,sucroferric oxyhydroxide,mesalamine,e verolimus,nitroglycerin,hydra lazine hcl,chloroquine Previous Value New Value 6 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 34 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name ethambutol hcl,promethazine hcl,zebutal,ketopr ofen,methimazole ,ciprofloxacin hcl,grispeg,phenadoz,co pegus,isosorbide dinitrate,cellcept, pramipexole dihydrochloride,m idodrine hcl,dayhist allergy,diphenhyd ramine hcl,ribavirin,velph oro,maxalt,asacol hd,bisacodyl,delzi col,myambutol,ge ntle laxative,afinitor disperz,nitrodur,hydralazine hcl,chloroquine phosphate,acarb ose,monodox,ferr ous gluconate,acetam inophen,morphin e sulfate er,phenazopyridi ne hcl,verapamil hcl,methyldopa,c hlorzoxazone,nic ardipine hcl,bisalax,ayr saline,methadone hcl,baby ayr saline,tapazole,s phosphate,acarbose,ferrous gluconate,acetaminophen,p henazopyridine hcl,verapamil hcl,methyldopa,chlorzoxazo ne,nicardipine hcl,sodium chloride,methadone hcl,acebutolol hcl,cinacalcet hcl,dronabinol,mycophenolat e sodium,dexamethasone,flut amide,enzalutamide,methaz olamide,nifedipine,potassiu m citrate,colestipol hcl,thyroid,pork,amiodarone hcl,mexiletine hcl,estropipate,albuterol sulfate,pindolol,flurbiprofen,t olbutamide,timolol maleate,codeine sulfate,leucovorin calcium Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 35 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value ectral,prevacid 24hr,banophen,a cebutolol hcl,sensipar,fever all,women's laxative,dronabin ol,mycophenolic acid,dexamethas one,doxycycline monohydrate,req uip,flutamide,gris eofulvin ultramicrosize,wo man's laxative,nitroglyc erin patch,xtandi,mart en-tab,cleocin hcl,margesic,met hazolamide,nifedi pine,potassium citrate er,neptazane,col estid,esgic,armou r thyroid,np thyroid,promethe gan,allergy relief,calcium citrate plus,acephen,pac erone,mexiletine hcl,deltasone,cle mastine fumarate,phenerg an,estropipate,pr ecose,cipro,albut erol sulfate,capacet,p yridium,butalbitalBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 36 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value acetaminophen,c alan,urocitk,nitrostat,dulcola x,heartburn relief 24 hour,fiorinal,duco dyl,mirapex,fioric et,tavist-1,fiorinal with codeine #3,dayhist,pindol ol,zofran odt,flurbiprofen,d davp,zofran,tolbu tamide,timolol maleate,biaxin,na turethroid,myfortic,m arinol,westhroid,s tarlix,heartburn treatment 24 hour,prevacid,am iodarone hcl,calcium citrate-vitamin d3,cardizem,phar bedryl,minitran,p arafon forte dsc,allerhist1,moderiba,codei ne sulfate,morphine sulfate,tylenolcodeine no.4,methadose,r ibasphere,alophe n pills,colestipol hcl,dolophine hcl,leucovorin calcium,dailyhistBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 37 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 1 01/25/2016 latanoprost,travo latanoprost,travoprost prost,xalatan (benzalkonium) REMOVE UM: QUANTITY 0.1 / day 01/25/2016 K-PHOS ORIGINAL REMOVE UM: QUANTITY 39.5 / day potassium phosphate,monobasic BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 38 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name 01/25/2016 celecoxib,danazo l,ibuprofen,quina pril hcl,ramipril,cepha lexin,carvedilol,m etronidazole,lisin opril,ibuprofen ib,furosemide,me toclopramide hcl,famciclovir,dip yridamole,methoc arbamol,repaglini de,fluconazole,hy droxyzine pamoate,fluoride, propranolol hcl,enalapril maleate,dilaudid, metoprolol succinate,spirono lactone,glyburide, hydroxyzine hcl,hydromorpho ne hcl,nitroglycerin,e rythromycin,dicycl omine hcl,nadolol,doxaz osin mesylate,bentyl,d examethasone,pr inivil,robaxin,ben azepril hcl,iron,fer-insol,reglan,zestril, children's iron,iprin,coreg,corgar d,walprofen,prandin,co Generic Name Type of Change celecoxib,danazol,ibuprofen, REMOVE UM: QUANTITY quinapril hcl,ramipril,cephalexin,carve dilol,metronidazole,lisinopril, furosemide,metoclopramide hcl,famciclovir,dipyridamole, methocarbamol,repaglinide,f luconazole,hydroxyzine pamoate,sodium fluoride,propranolol hcl,enalapril maleate,hydromorphone hcl,metoprolol succinate,spironolactone,gly buride,hydroxyzine hcl,nitroglycerin,erythromyci n base,dicyclomine hcl,nadolol,doxazosin mesylate,dexamethasone,b enazepril hcl,ferrous sulfate,colestipol hcl,nicotine,dicloxacillin sodium,sevelamer hcl,budesonide,ampicillin trihydrate,mesalamine Previous Value New Value 16 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 39 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value lestid,nicotrol,ferr ous sulfate,motrin ib,dicloxacillin sodium,aldactone ,mediprofen,renagel,bu desonide,ampicilli n trihydrate,celebre x,vistaril,flagyl,ac cupril,lasix,diabet a,persantine,pent asa,provil,advil,a dvil liquigels,colestipol hcl,advil migraine,diflucan, cardura,famvir,pu lmicort,toprol xl,keflex,vasotec, nitro-time,feriron,ludent fluoride,altace,chi ldren's ferrous sulfate 01/25/2016 EPOGEN,PROC epoetin alfa RIT REMOVE UM: QUANTITY 0.14 / day 01/25/2016 ATROVENT HFA ipratropium bromide REMOVE UM: QUANTITY 0.774 / day 01/25/2016 prednisone,ropini role hcl,dexamethaso ne,menest,amoxi cillin,premarin,req uip REMOVE UM: QUANTITY 48 / day 01/25/2016 mapap,acetamin acetaminophen ophen REMOVE UM: QUANTITY 124.923 / day prednisone,ropinirole hcl,dexamethasone,estroge ns,esterified,amoxicillin,estr ogens, conjugated BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 40 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date 01/25/2016 Brand Name Generic Name children's nonacetaminophen aspirin,children's pain relief,children's pain-fever,infants' pain-fever,pain relief,fever reducer-pain reliever,children's pain reliever,children's acetaminophen,in fants' pain reliever,children's silapap,infants' pain relief,acetaminop hen,infant painfever,infant pain relief,infant's pain relief,little remedies feverpain,children's tylenol,qpap,children's qpap,infants' tylenol,infant fever-pain reliever,nonaspirin,mapap,inf ants' mapap,children's meditabs,pediacare fever reducer,nortemp, betatemp,edapap Type of Change Previous Value REMOVE UM: QUANTITY 125 / day New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 41 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value 01/25/2016 clotrimazole,mico clotrimazole,miconazole nazole nitrate,terconazole 7,miconazole nitrate,gynelotrimin7,terconazole,ter azol 7,monistat 7,zazole,clotrima zole-7 REMOVE UM: QUANTITY 6.429 / day 01/25/2016 methotrexate methotrexate sodium REMOVE UM: QUANTITY 1.619 / day 01/25/2016 PREMARIN estrogens, conjugated REMOVE UM: QUANTITY 66 / day 01/25/2016 hydrocodonehydrocodone acetaminophen,h bitartrate/acetaminophen ycet REMOVE UM: QUANTITY 180 / day 01/25/2016 proair albuterol sulfate,tobramycin hfa,proventil hfa,tobramycin,ve ntolin hfa,tobrex REMOVE UM: QUANTITY 1.6 / day 01/25/2016 CREON lipase/protease/amylase REMOVE UM: QUANTITY 28.078 / day 01/25/2016 ortho evra,testosterone cypionate,alendro nate sodium,depotestosterone,estr adiol,xulane,clim ara norelgestromin/ethinyl estradiol,testosterone cypionate,alendronate sodium,estradiol REMOVE UM: QUANTITY 0.154 / day 01/25/2016 acetaminophen- acetaminophen with codeine REMOVE UM: QUANTITY codeine,morphin phosphate,morphine sulfate e sulfate 01/25/2016 ibandronate sodium,boniva 01/25/2016 trifluridine,viroptic trifluridine ibandronate sodium New Value 90 / day REMOVE UM: QUANTITY 0.044 / day REMOVE UM: QUANTITY 0.9 / day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 42 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name 01/25/2016 warfarin sodium,metformi n hcl,sulindac,levot hyroxine sodium,metformi n hcl er,montelukast sodium,verapamil er,allopurinol,jant oven,flecainide acetate,sotalol af,levoxyl,sotalol, unithroid,coumadi n,calan sr,tambocor,sorin e,zyloprim,synthr oid,singulair,beta pace,betapace af,glucophage,glu cophage xr 01/25/2016 dexamethasone sodium phosphate Generic Name Type of Change Previous Value warfarin sodium,metformin hcl,sulindac,levothyroxine sodium,montelukast sodium,verapamil hcl,allopurinol,flecainide acetate,sotalol hcl REMOVE UM: QUANTITY 2.5 / day dexamethasone sod phosphate REMOVE UM: QUANTITY 3.6 / day New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 43 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date 01/25/2016 Brand Name Generic Name antacid,antacid magnesium plus antihydroxide/aluminum gas,antacidhydroxide/simethicone antigas,rimox,antacid m,flanax,liquid antacid,advanced antacidantigas,antacid with simethicone,gerimox,almacone,rigel,mintox,advan ced antacid,comfort gel,maalox advanced,mag-al plus,gerilanta,maglox,rulo x,mi acid Type of Change Previous Value REMOVE UM: QUANTITY 360 / Day New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 44 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value 01/25/2016 antacidmagnesium antigas,antacid hydroxide/aluminum maximum hydroxide/simethicone strength,comfort gel,antacid extra strength,antacid plus antigas,antacid,alma cone-2,antacid & antigas,masanti,a dvanced antacidantigas,mintox maximum strength,liquid antacid,gelusil,an tacid anti-gas double str,maalox maximum strength,antacid ii plus simethicone,magal plus xs,antacid with simethicone,ri-gel ii,antacid & gas relief,mi-acid REMOVE UM: QUANTITY 288 / Day 01/25/2016 CREON lipase/protease/amylase REMOVE UM: QUANTITY 90.9 / day 01/25/2016 CREON lipase/protease/amylase REMOVE UM: QUANTITY 42.1 / day 01/25/2016 QVAR beclomethasone dipropionate REMOVE UM: QUANTITY 0.876 / day 01/25/2016 CREON lipase/protease/amylase REMOVE UM: QUANTITY 168.3 / day 01/25/2016 QVAR beclomethasone dipropionate REMOVE UM: QUANTITY 0.435 / day New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 45 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value 01/25/2016 brimonidine tartrate,tacrolimu s,prograf,dorzola mide hcl,trusopt,alphag an p,vigamox,victoz a 3-pak,victoza 2pak,hecoria brimonidine REMOVE UM: QUANTITY tartrate,tacrolimus,dorzolami de hcl,moxifloxacin hcl,liraglutide 01/25/2016 TUDORZA PRESSAIR aclidinium bromide REMOVE UM: QUANTITY 0.066 / day 01/25/2016 AEROSPAN flunisolide REMOVE UM: QUANTITY 0.593 / day 01/25/2016 imitrex,sumatripta sumatriptan succinate n succinate REMOVE UM: QUANTITY 2 / 30 days 01/25/2016 methylprednisolo methylprednisolone,chlorpro ne,medrol,chlorpr pamide opamide REMOVE UM: QUANTITY 7.5 / day 01/25/2016 pediatric electrolytes/dextrose electrolyte,pedial yte advanced care,pediatric freezer pops,pedialyte,en falyte,pedialyte electrolyte singles,oralyte,en famil enfalyte REMOVE UM: QUANTITY 5000 / day 01/25/2016 cyclosporine cyclosporine, modified,cyclosp modified,cyclosporine orine,gengraf,neo ral,sandimmune REMOVE UM: QUANTITY 0.12 / day 01/25/2016 nasal allergy cromolyn sodium spray,cromolyn sodium,nasalcro m REMOVE UM: QUANTITY 0.78 / day New Value 0.3 / day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 46 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change 01/25/2016 infant's ibuprofen,infants ibuprofen,infants' ibuprofen,metocl opramide hcl,infant's motrin,cefpodoxi me proxetil,furadanti n,cephalexin,pred nisolone sodium phosphate,cypro heptadine hcl,nitrofurantoin,i nfants ibudrops,penicillin v potassium,difluca n,infants' motrin,fluconazol e,infants mediprofen,infants profenib,dicyclom ine hcl,albuterol sulfate,sulfameth oxazoletrimethoprim,pedi apred,ampicillin trihydrate,ibuprof en,sulfatrim,ibudrops,children's ibuprofen 01/25/2016 cyclosporine cyclosporine, modified,sandim modified,cyclosporine mune,cyclosporin e,gengraf,neoral REMOVE UM: QUANTITY 0.48 / day 01/25/2016 nasacort,children' triamcinolone acetonide s nasacort,nasal allergy REMOVE UM: QUANTITY 0.72 / day ibuprofen,metoclopramide REMOVE UM: QUANTITY hcl,cefpodoxime proxetil,nitrofurantoin,cephal exin,prednisolone sod phosphate,cyproheptadine hcl,penicillin v potassium,fluconazole,dicycl omine hcl,albuterol sulfate,sulfamethoxazole/tri methoprim,ampicillin trihydrate Previous Value New Value 80 / day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 47 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name cyclosporine, modified Type of Change Previous Value REMOVE UM: QUANTITY 0.24 / day 01/25/2016 cyclosporine modified 01/25/2016 methylprednisolo methylprednisolone ne,medrol REMOVE UM: QUANTITY 3.75 / day 01/25/2016 azathioprine,imur azathioprine an REMOVE UM: QUANTITY 0.06 / day 01/25/2016 sumatriptan sumatriptan succinate succinate,alsuma ,imitrex REMOVE UM: QUANTITY 1 / 30 days 01/25/2016 acyclovir,azithro acyclovir,azithromycin,estro mycin,menest,zit gens,esterified,estrogens, hromax,premarin, conjugated zovirax REMOVE UM: QUANTITY 100 / day 01/25/2016 children's ibuprofen,cephalexin,ampicil REMOVE UM: QUANTITY ibuprofen,ibuprof lin trihydrate,propranolol hcl en,child ibuprofen,cephal exin,children's motrin,children's profenib,children' s mediprofen,children's advil,children's profen ib,ampicillin trihydrate,propran olol hcl 160 / day 01/25/2016 atrovent,ipratropi ipratropium bromide um bromide REMOVE UM: QUANTITY 0.84 / day 01/25/2016 atrovent,ipratropi ipratropium bromide um bromide REMOVE UM: QUANTITY 1.61 / day New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 48 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name 01/25/2016 timolol maleate,combive nt respimat,eye itch relief,zaditor,itchy eye,children's alaway,ketotifen fumarate,cosopt, dorzolamidetimolol,levobunol ol hcl,antihistamine eye drops,betagan,w al-zyr,allergy eye,carteolol hcl,timoptic,alawa y,allergy eye drops 01/25/2016 Generic Name Type of Change Previous Value timolol maleate,ipratropium bromide/albuterol sulfate,ketotifen fumarate,dorzolamide hcl/timolol maleate,levobunolol hcl,carteolol hcl REMOVE UM: QUANTITY 0.2 / day CHANTIX varenicline tartrate REMOVE UM: QUANTITY 53 / 270 days 01/25/2016 ARANESP darbepoetin alfa in polysorbate 80 REMOVE UM: QUANTITY 2.938 / day 01/25/2016 CREON,ZENPEP lipase/protease/amylase REMOVE UM: QUANTITY 336.67 / day 01/25/2016 NEUPOGEN REMOVE UM: QUANTITY 0.033 / day filgrastim New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 49 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value 01/25/2016 lidocaine hcl viscous,amoxicilli n,antihist,promet hazine hcl,acetylcysteine ,prednisone,clind amycin pediatric,children' s allergy,oxycodon e hcl,cleocin palmitate,hydroco doneacetaminophen,cl indamycin palmitate hcl,meperidine hcl,diphenhydram ine hcl,valu-dryl lidocaine REMOVE UM: QUANTITY hcl,amoxicillin,diphenhydra mine hcl,promethazine hcl,acetylcysteine,prednison e,clindamycin palmitate hcl,oxycodone hcl,hydrocodone bitartrate/acetaminophen,me peridine hcl 01/25/2016 potassium chloride,k-sol potassium chloride REMOVE UM: QUANTITY 112.5 / day 01/25/2016 DULERA mometasone furoate/formoterol fumarate REMOVE UM: QUANTITY 0.433 / day 01/25/2016 potassium chloride,k-sol potassium chloride REMOVE UM: QUANTITY 56.25 / day 01/25/2016 minivelle,alora,es estradiol tradiol,vivelle-dot REMOVE UM: QUANTITY 0.319 / day New Value 120 / day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 50 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value 01/25/2016 stool docusate sodium softener,docusat e sodium,move it along,silace,dok, docusol kids,promolaxin,d ss,colrite,enemeez,cola ce,colace clear,womens stool softener,pedialax stool softener,soflax,docusil,docu soft,diocto,doc-qlace,docu liquid,dulcolax stool softener,phillips' laxative,docusol, docuprene,dioctyl REMOVE UM: QUANTITY 5 / 1 days 01/25/2016 trustex-ria REMOVE UM: QUANTITY 1.2 / days 01/25/2016 econazole nitrate econazole nitrate REMOVE UM: QUANTITY 30 / 30 days condoms, latex, lubricated New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 51 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value 01/25/2016 stool softenersennosides/docusate stimulant sodium lax,medi-natural senna stool soft,stool softener,stool softenerlaxative,sennas,sennosidesdocusate sodium,senna plus,senna s,senokots,senna laxative,p-col rite,docusate sodiumsenna,sennatime s,lax stool softener with senna,doc-qlax,senexons,senna-docusate sodium,pericolace,medilaxx,laxacin,senn alax-s,dok plus,stimulant laxative plus REMOVE UM: QUANTITY 12 / 1 days 01/25/2016 PROCRIT REMOVE UM: QUANTITY 0.011 / day epoetin alfa New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 52 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value 01/25/2016 medi-lax,senna sennosides laxative,senna,la xative,laxative pills,medinatural,laxative maximum strength,vegetabl e laxative,natural senna laxative,laxativesenna,senno,cho colated laxative,perdiem, senna lax,senexon,seno kotxtra,senokot,s enokot to go,seno-tab,natural vegetable laxative,evac-ugen,geri-kot,black draught senna laxative,exlax,ex-lax maximum strength,sennaextra,natural laxative REMOVE UM: QUANTITY 11.5 / 1 days 01/25/2016 loperamide REMOVE UM: QUANTITY 8 / 1 days 01/25/2016 diltiazem 24hr diltiazem hcl er,diltiazem 24hr cd REMOVE UM: QUANTITY 1 / 1 days 01/25/2016 amoxicillinclavulanate potass amoxicillin/potassium clavulanate REMOVE UM: QUANTITY 21.875 / day 01/25/2016 lactulose lactulose REMOVE UM: QUANTITY 240 / 1 days loperamide hcl New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 53 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name 01/25/2016 acid reducer,carvedilol ,motion sickness relief,cyclobenza prine hcl,bisoprolol fumarate,hydroch lorothiazide,lisino prilhydrochlorothiazi de,travel sickness,arbinox a,omeprazole,isr adipine,metformi n hcl er,amlodipine besylate,lovastati n,naproxen sodium,chlorphen iramine maleate,diltiazem hcl,furosemide,is osorbide mononitrate er,meclizine hcl,nifedipine er,atenolol,mema ntine hcl,baclofen,ama ntadine,ibuprofen ,celebrex,sotalol, warfarin sodium,spironola ctone,diltiazem er,sulfamethoxaz oletrimethoprim,neo mycin-polymyxinhc,neomycin- Generic Name Type of Change famotidine,carvedilol,meclizi REMOVE UM: QUANTITY ne hcl,cyclobenzaprine hcl,bisoprolol fumarate,hydrochlorothiazid e,lisinopril/hydrochlorothiazi de,carbinoxamine maleate,omeprazole,isradipi ne,metformin hcl,amlodipine besylate,lovastatin,naproxen sodium,chlorpheniramine maleate,diltiazem hcl,furosemide,isosorbide mononitrate,nifedipine,ateno lol,memantine hcl,baclofen,amantadine hcl,ibuprofen,celecoxib,sotal ol hcl,warfarin sodium,spironolactone,sulfa methoxazole/trimethoprim,n eomycin sulfate/polymyxin b sulfate/hydrocortisone,nabu metone,losartan potassium,diclofenac sodium,cefadroxil,calcium carbonate/cholecalciferol (vitamin d3),glipizide,enalapril maleate,glimepiride,doxazos in mesylate,cefuroxime axetil,atorvastatin calcium,pravastatin sodium,quinapril hcl,calcium phosphat/magnesium hydroxide/vit c/vit d3/phosphorus,zanamivir,gly buride,irbesartan,naproxen, oxybutynin chloride,simvastatin,glyburid e/metformin Previous Value New Value 4 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 54 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name polymyxinhydrocort,nabum etone,allerchlor,losartan potassium,diclofe nac sodium,cefadroxil ,calcium 600-vit d3,glipizide,enala pril maleate,famotidin e,glimepiride,dox azosin mesylate,cefuroxi me,atorvastatin calcium,chlortabs ,pravachol,quinap ril hcl,procal,relenza,glybur ide,irbesartan,na prosyn,anaprox,o xybutynin chloride,simvasta tin,glyburidemetformin hcl,bonine,digoxi n,lisinopril,valacy clovir,pravastatin sodium,ecnaprosyn,levothyr oxine sodium,minocycli ne hcl,ramipril,metop rolol succinate,fluorita b,januvia,oyster shell calcium-vit d3,prinivil,allergy hcl,digoxin,lisinopril,valacycl ovir hcl,levothyroxine sodium,minocycline hcl,ramipril,metoprolol succinate,sodium fluoride,sitagliptin phosphate,calcium carbonate/ergocalciferol (vitamin d2),felodipine,calcium cit/magnesium/d3/zinc ox/copper gluc/manganese/boron,calci um citrate/cholecalciferol (vitamin d3),everolimus,vorinostat,ab iraterone acetate,cefprozil,calcium carb,citrate/vitamin d3/mineral comb no.34/genistein,hyoscyamin e sulfate,rifampin,metolazone, carbidopa/levodopa,tamoxif en citrate,amlodipine besylate/benazepril hcl,nitrofurantoin macrocrystal,trandolapril,pra zosin hcl,nadolol,famciclovir,azithr omycin,penicillin v potassium,benazepril hcl,hydroxychloroquine sulfate,morphine sulfate,ketoprofen,misoprost ol,indomethacin,ropinirole hcl,indapamide,niacin,propr anolol hcl,perindopril erbumine,pseudoephedrine Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 55 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name relief,oyster shell calcium w-vit d,felodipine er,citracal-vit d + magnesium,citrac al + d maximum,lanoxin ,afinitor disperz,zolinza,zy tiga,cefprozil,dilti azem 24hr cd,citracal + bone density,levbid,zoc or,mevacor,rifam pin,metolazone,c ozaar,calcium 500-vit d3,carbidopalevodopa er,tamoxifen citrate,amlodipine besylatebenazepril,zestor etic,nitrofurantoin ,zestril,trandolapri l,pepcid,tenormin, prazosin hcl,sinemet cr,carbinoxamine maleate,calcium citrate-vitamin d,corgard,famcicl ovir,azithromycin, oyster shell calcium-vitamin d,penicillin v potassium,benaz epril hcl,hydroxychloro hcl,glyburide,micronized,don epezil hcl,rivastigmine tartrate,medroxyprogesteron e acetate,tolterodine tartrate,potassium bicarbonate/citric acid,ranitidine hcl,glipizide/metformin hcl,trimethoprim,nicotine,tini dazole,tolazamide,isosorbid e dinitrate,flecainide acetate,cimetidine,fluconazo le,mexiletine hcl,epinephrine,dimethyl fumarate,ranolazine,verapa mil hcl,progesterone,micronized ,fosinopril sodium,chlorthalidone,danaz ol,chlorothiazide,probenecid, ketorolac tromethamine,colchicine/pro benecid,thyroid,pork,colchici ne,cilostazol,bethanechol chloride,alendronate sodium,terazosin hcl,isoniazid,valsartan,potas sium chloride/potassium bicarbonate/citric acid,dexamethasone,leucov orin calcium,amoxicillin/potassiu m clavulanate,multivitamin with minerals/folic acid/lutein/zeaxanthin,calciu m cit/vit d3/vit k/mag ox/strontium cit/sodium borate,nicardipine hcl,enalapril Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 56 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name quine sulfate,morphine sulfate er,ketoprofen,cor eg,misoprostol,le voxyl,indomethac in,medimeclizine,requip,i ndapamide,isosor bide mononitrate,nias pan,propranolol hcl er,perindopril erbumine,pseudo ephedrine hcl,glynase,done pezil hcl,allergy,rivasti gmine,celecoxib, calcium citrate vitamin d3,provera,detrol, motion sickness,sorine,a cid controller,calcium citrate+d,klorcon-ef,glipizide er,glipizidemetformin,trimeth oprim,diltiazem 24hr er,nicotrol ns,tinidazole,tiaz ac,wal-zan 75,heartburn prevention,tolaza mide,isosorbide dinitrate,medroxy progesterone maleate/hydrochlorothiazide ,varenicline tartrate,nitroglycerin,multivit with calcium-mins/iron fumarate/folic acid/vit k,fluvastatin sodium,cefpodoxime proxetil,niacinamide/azelaic acid/zinc oxide/vit b6/copper/fa,tetracycline hcl,estradiol,omega-3 acid ethyl esters,quinidine sulfate,cinacalcet hcl,bosentan,hydromorphon e hcl,hydroxyzine pamoate Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 57 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value acetate,flecainide acetate,zantac 75,cimetidine,fluc onazole,mexiletin e hcl,auviq,glipizide xl,naproxen,pepci d ac,avapro,cytotec ,aldactone,tecfide ra,ranexa,plaque nil,motion relief,calan,verap amil sr,calan sr,afeditab cr,lasix,diabeta,o yster shell calcium,verapami l er,progesterone,f osinopril sodium,amaryl,ch lorthalidone,prom etrium,danazol,ra nitidine hcl,chlorothiazide ,probenecid,taztia xt,diltia xt,digox,symaxsr,epinephrine,ca rtia xt,ketorolac tromethamine,adr enaclick,cardize m,probenecidcolchicine,cardize m cd,ropinirole hcl,naturethroid,glucotrol,di gitek,westhroid,c BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 58 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value ardura,niacin er,diflucan,colcry s,antivert,glucotro l xl,cilostazol,verel an,verelan pm,bethanechol chloride,tamboco r,alendronate sodium,terazosin hcl,isoniazid,dra mamine less drowsy,valsartan, wal-finate,k effervescent,lude nt fluoride,potassiu m chloride,sotalol af,dexamethason e,altace,cortispori n,lotensin,leucov orin calcium,oscimin sr,amoxicillinclavulanate pot er,calcium citrate - vitamin d,zaroxolyn,tolter odine tartrate,augmenti n xr,jantoven,icaps mv,coumadin,dio van,ambizine,cal cium citrate-vit d,verapamil er pm,allergy 4hour,sudogest,po tassium BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 59 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value bicarbonate,vera pamil hcl,calcium,thera cal,prosteon,supe r calcium 600-vit d3,bactrim ds,aceon,calcitrat e + vit d,nicardipine hcl,heartburn relief,nadolol,glyb uride micronized,enala prilhydrochlorothiazi de,norvasc,chanti x,minipress,proca rdia xl,zithromax,zithr omax tripak,rifadin,urech oline,zebeta,mavi k,minocin,lipitor,a ccupril,nitrostat,m otion sickness ii,inderal la,synthroid,lotrel, famvir,optisource, dilt-xr,exelon,diltcd,chlorhist,diltza c er,lescol,cefpodo xime proxetil,fluvastati n sodium,pharbechl or,hyoscyamine sulfate er,chlortrimeton,afinitor,o BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 60 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value ystercal-d,vpzel,os-cal 500-vit d3,ms contin,oyster shell + d,calcium 600 + vit d,adalat cc,tetracycline hcl,nicazel,estrac e,imdur,glucovan ce,glucophage xr,hi-cal,trizel,fluoride,efferk,nifedical xl,omega-3 acid ethyl esters,colchicine, quinidine sulfate,calcium citrate-vitamin d3,verticalm,aller gy-time,epipen jr 2-pak,betapace af,betapace,pletal ,acid control,hyoscyam ine sulfate sr,unithroid,arice pt,palgic,edchlortan,sensipar, calcium 500 + vitamin d,namenda,motio ntime,tracleer,moti on sickness relief ii,tindamax,hydro morphone hcl,sodium fluoride,lovaza,va BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 61 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value ltrex,macrodantin ,ceftin,hydroxyzin e pamoate,oysco 500-vit d3,toprol xl,vasotec,prilose c,oysco d,citrus calcium + d 01/25/2016 nasacort triamcinolone acetonide aq,triamcinolone acetonide REMOVE UM: QUANTITY 0.55 / day 01/25/2016 ARMOUR THYROID REMOVE UM: QUANTITY 0.813 / day thyroid,pork BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 62 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name 01/25/2016 daily gummies,omepra zole magnesium,aten olol,torsemide,aci d reducer,ranitidine hcl,meloxicam,lisi noprilhydrochlorothiazi de,bisoprolol fumarate,atorvast atin calcium,theophylli ne,isradipine,spe ctravite cardio health,lipitor,done pezil hcl,nifedipine er,docusate calcium,memanti ne hcl,omeprazole,a mlodipine besylate,losartan potassium,losarta nhydrochlorothiazi de,metoprolol succinate,naprox en,warfarin sodium,sotalol,dil tiazem er,glucagon emergency kit,montelukast sodium,minocycli ne hcl,ofloxacin,gem Generic Name Type of Change multivitamin with REMOVE UM: QUANTITY minerals/folic acid,omeprazole magnesium,atenolol,torsemi de,ranitidine hcl,meloxicam,lisinopril/hydr ochlorothiazide,bisoprolol fumarate,atorvastatin calcium,theophylline anhydrous,isradipine,multivit with calcium,iron,minerals/folic acid/phytosterol,donepezil hcl,nifedipine,docusate calcium,memantine hcl,omeprazole,amlodipine besylate,losartan potassium,losartan potassium/hydrochlorothiazi de,metoprolol succinate,naproxen,warfarin sodium,sotalol hcl,diltiazem hcl,glucagon,human recombinant,montelukast sodium,minocycline hcl,ofloxacin,gemfibrozil,nab umetone,granisetron hcl,pravastatin sodium,diclofenac sodium,multivits, ca, minerals/iron fumarate/folic acid,multivitamin/folic acid/docosahexanoic acid,entecavir,famotidine,en alapril maleate,glimepiride,cefuroxi me axetil,lovastatin,cetirizine hcl,simvastatin,ciprofloxacin hcl,quinapril Previous Value New Value 2 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 63 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name fibrozil,one-a-day vitacraves,nabum etone,one-a-day vitacraves immunity,one-aday vitacraves sour,granisetron hcl,pravastatin sodium,diclofena c sodium,one-aday men vitacraves,one-aday women vitacraves,one-aday women's petites,one-a-day vitacraves omega3,baraclude,famo tidine,enalapril maleate,glimepiri de,cefuroxime,lov astatin,cetirizine hcl,simvastatin,pr avachol,ciproflox acin hcl,quinapril hcl,valcyte,tamiflu ,irbesartan,valsar tanhydrochlorothiazi de,orphenadrine citrate,indapamid e,verapamil er,naprosyn,anap rox ds,digoxin,centru m,tamsulosin hcl,ramipril,levoth yroxine hcl,valganciclovir hcl,oseltamivir phosphate,irbesartan,valsart an/hydrochlorothiazide,orph enadrine citrate,indapamide,verapami l hcl,naproxen sodium,digoxin,folic acid/multivit with fe,other mineral,tamsulosin hcl,ramipril,levothyroxine sodium,lisinopril,sitagliptin phosphate/metformin hcl,calcium carbonate/cholecalciferol (vitamin d3),felodipine,sitagliptin phosphate,cefdinir,cefprozil,i rbesartan/hydrochlorothiazid e,chlorpheniramine maleate,leucovorin calcium,trandolapril,sulindac ,amlodipine besylate/benazepril hcl,varenicline tartrate,fondaparinux sodium,triamterene/hydrochl orothiazide,glipizide,nitrofura ntoin monohydrate/macrocrystals, pantoprazole sodium,tolterodine tartrate,isosorbide mononitrate,acetazolamide, calcium carbonate/vit d3/mag ox/zinc/copper/manganese/ boron,multivit with calcium, iron, and other Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 64 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name sodium,lisinopril,j anumet xr,caltrate 600 plus d3,felodipine er,singulair,januvi a,cefdinir,diclofen ac sodium er,lanoxin,cefproz il,irbesartanhydrochlorothiazi de,zocor,hyzaar, mevacor,janumet ,cozaar,chlorphe n sr,diltiazem 24hr cd,zestoretic,leuc ovorin calcium,zestril,tra ndolapril,pepcid,t enormin,sulindac, amlodipine besylatebenazepril,chanti x,arixtra,dyazide, glipizide xl,nitrofurantoin monomacro,pantopraz ole sodium,tolterodin e tartrate,levoxyl,m en's daily gummies,adult multi gummies,calcium 600-vit d3,isosorbide mononitrate,acet minerals,polyethylene glycol 3350,rivastigmine tartrate,zolmitriptan,medroxy progesterone acetate,acitretin,terbinafine hcl,multivits, iron, minerals combo no #5, folic acid,glyburide,micronized,pr opranolol hcl,indomethacin,celecoxib,k etoconazole,rifabutin,trospiu m chloride,prochlorperazine,ca lcium carb/mag oxide/vitamin d3/vit b12/fa/vit b6/boron,enalapril maleate/hydrochlorothiazide ,fenofibrate,micronized,prim aquine phosphate,epinephrine,fenof ibrate,bupropion hcl,multivitamin with minerals/folic acid/lycop/lut/herbal 178,dimethyl fumarate,ranolazine,ambrise ntan,amoxicillin/potassium clavulanate,tamoxifen citrate,hydrochlorothiazide,p rogesterone,micronized,eno xaparin sodium,linagliptin/metformin hcl,methyclothiazide,doxazo sin mesylate,acetic acid/hydrocortisone,benaze pril hcl,thyroid,pork,niacin,febux ostat,estrogens, conjugated,flunisolide,predni Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 65 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name azolamide,calciu m plus vitamin d,multiple vitamins for women,polyethyl ene glycol 3350,rivastigmine ,zolmitriptan,gluc otrol xl,provera,acitreti n,terbinafine hcl,strovite forte,triamterenehydrochlorothiazi d,kaopectate,detr ol,sorine,glynase, allergy relief,flomax,ente cavir,diltiazem 24hr er,glipizide er,propranolol hcl er,wal-zan 150,detrol la,healthylax,tiaz ac,indomethacin, one daily maximum,century cardio,celecoxib, acid control,ketoconaz ole,mycobutin,sa nctura,prochlorpe razine,stool softener,folgard os,enalaprilhydrochlorothiazi de,lofibra,primaq uine,auviq,avalide,avapro, sone,fosinopril sodium,cilostazol,methenam ine hippurate,valsartan,bisoprol ol fumarate/hydrochlorothiazid e,amiloride hcl,griseofulvin, microsize,folic acid/multivitamin with minerals/lutein,leflunomide,c alcium citrate/magnesium oxide/vitamin d3/pyridoxine/min,metolazon e,oxybutynin chloride,guanfacine hcl,estrogens,esterified/met hyltestosterone,terazosin hcl,cimetidine,amiloride hcl/hydrochlorothiazide,meth yldopa/hydrochlorothiazide,b etaxolol hcl,paricalcitol,sodium picosulfate/magnesium oxide/citric acid,dalfampridine,selegiline hcl,fluvastatin sodium,everolimus,aliskiren hemifumarate,formoterol fumarate,cefadroxil,calcium carbonate,calcium gluconate/ergocalciferol (vit d2),rimantadine hcl,vit a/c/e acetate/zinc oxide/sodium selenate/cupric oxide,lenalidomide,tadalafil, beta-carotene (vit a) with vitamins c and e/minerals,bosentan,calcium /multivitamin with Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 66 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name bupropion hcl sr,mega multi,tecfidera,ra nexa,letairis,amo xicillinclavulanate potass,isosorbide mononitrate er,glucagen,tamo xifen citrate,minocin,hy drochlorothiazide, celebrex,calan sr,verapamil sr,afeditab cr,mobic,zantac,p rogesterone,amar yl,enoxaparin sodium,jentaduet o,prometrium,tazt ia xt,methyclothiazi de,demadex,diltia xt,mega multivitamin,doxa zosin mesylate,cardize m cd,trospium chloride,epinephri ne,cartia xt,adrenaclick,ma xzide-25 mg,hydrocortison e-acetic acid,benazepril hcl,digitek,naturethroid,westhroid,c ardura,niacin er,womens daily iron,ruxolitinib phosphate,multivitamin,salm eterol xinafoate,betacarotene(a) w-c and e/lutein/minerals,rivaroxaba n Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 67 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value gummies,zomig,u loric,premarin,sm oothlax,glyburide micronized,flunis olide,verelan pm,verelan,predn isone,fosinopril sodium,cilostazol, centrum specialist heart,methenami ne hippurate,tolterod ine tartrate er,valsartan,bisop rololhydrochlorothiazi de,sotalol af,altace,kaotin,amiloride hcl,lotensin,grise ofulvin,np thyroid,augmenti n,spectravite adult,jantoven,mu ltivitamin,diovan,va lganciclovir hcl,coumadin,adu lt multivitamin gummies,grifulvin v,leflunomide,fen ofibrate,calcium citrate plus,fondaparinux sodium,adult one daily gummies,metolaz one,verapamil er BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 68 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value pm,men's multivitamin,com pazine,oxybutyni n chloride er,naproxen sodium,women's multivitamin,tene x,guanfacine hcl,estrogen & methyltestosteron e,terazosin hcl,cimetidine,am iloridehydrochlorothiazi de,methyldopahydrochlorothiazi de,norvasc,multiv itamins wcalciumiron,procardia xl,hiprex,ziac,zeb eta,diamox sequels,mavik,ni aspan,tl g-fol os,chlorphenirami ne maleate,betaxolol hcl,lopid,accupril, synthroid,heartbu rn relief,zemplar,ind eral la,prepopik,lotrel, one daily with calciumiron,ampyra,sele giline hcl,paricalcitol,dilt -cd,dilt-xr,diovan BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 69 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value hct,exelon,one daily complete,lescol,l amisil,fluvastatin sodium,lovenox,ri fabutin,imdur,diltz ac er,eemt h.s.,afinitor,tektur na,voltarenxr,arava,heartbur n relief 150,central-vite cardio,adalat cc,foradil,estroge nmethyltestosteron e,cefadroxil,nifedi cal xl,buproban,parv a-cal 500,flumadine,vo sol hc,medroxyproge sterone acetate,prosight,c alcium citrate + d,miralax,covaryx h.s.,theophylline anhydrous,epipe n 2pak,eldepryl,revli mid,betapace af,rimantadine hcl,betapace,plet al,unithroid,one daily for women,digox,aric ept,century,adcirc a,century cardio BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 70 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value health formula,ocutabs,s urfak,acetasol hc,namenda,arm our thyroid,soriatane, tracleer,vision,co mpro,fosfree,jaka fi,chewable multi vitamin,zyban,ser event diskus,macrobid, ceftin,acid reducer 150,dilacor xr,eye health plus lutein,nutricap,top rol xl,purelax,vasote c,vaseretic,one daily gummy vites,chewablevite,prilosec,xarel to 01/25/2016 zazole,terconazol terconazole e,terazol 3 REMOVE UM: QUANTITY 6.667 / day 01/25/2016 NEUPOGEN filgrastim REMOVE UM: QUANTITY 0.017 / day 01/25/2016 amoxicillinclavulanate potass amoxicillin/potassium clavulanate REMOVE UM: QUANTITY 43.75 / day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 71 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name 01/25/2016 pioglitazone hcl,allergy relief,atenolol,fen ofibrate,bicalutam ide,daily multiple vitamin,meloxica m,atenololchlorthalidone,nic otine patch,cyclafem,bi sacodyl,spectravi te energy metabolism,emoq uette,diltiazem 24hr cd,gildess,loratad ine,atorvastatin calcium,icar-c plus,women's daily formula,nifedipine er,simvastatin,pla vix,montelukast sodium,clopidogr el,diltiazem er,pravastatin sodium,warfarin sodium,one-aday women's healthy skin,stress b with zinc,one-a-day menopause formula,losartan potassium,one-aday women's 50+,one-a-day men's 50 plus,central-vite Generic Name Type of Change pioglitazone REMOVE UM: QUANTITY hcl,loratadine,atenolol,fenofi brate nanocrystallized,bicalutamid e,multivitamin,meloxicam,at enolol/chlorthalidone,nicotin e,norethindrone-ethinyl estradiol,bisacodyl,multivita min-minerals/iron fumarate/folic acid/panax ginseng,desogestrel-ethinyl estradiol,diltiazem hcl,norethindrone acetateethinyl estradiol,atorvastatin calcium,iron,carbonyl/ascorb ic acid/cyanocobalamin/folic acid,cetirizine hcl,multivits, ca, minerals/iron fumarate/folic acid,nifedipine,simvastatin,cl opidogrel bisulfate,montelukast sodium,pravastatin sodium,warfarin sodium,multivitamin with calcium, minerals/iron/folic acid/lutein,multivitamin,stres s formula/zinc,multivitamin with calcium, mineral/folic acid/soy isoflavone,losartan potassium,multivitamin with minerals/folic acid/calcium carb/vit k1,multivitamin with minerals/folic acid/phytonadione/lycopene, multivitamin with minerals/folic acid/lycopene/lutein,ranitidin e hcl,folic acid/multivitamin Previous Value New Value 1 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 72 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name senior,ranitidine hcl,therapeuticm,sentry senior,sentry,fallb ack solo,orsythia,levo floxacin,baraclud e,losartanhydrochlorothiazi de,pirmella,alyac en,cetirizine hcl,pravachol,ana strozole,irbesarta n,valsartanhydrochlorothiazi de,levothyroxine sodium,centrum complete,centru m silver,pantoprazol e sodium,proscar,a mlodipine besylate,finasteri de,centrum silver ultra women's,centrum silver ultra men's,one-aday,daily multivitamin with iron,one-a-day women's,janumet xr,one daily multivitamin,onea-day essential,one-aday men's,theratabs,thera-tabs with minerals/lutein,multivitamin/f errous fumarate/folic acid,levonorgestrel,levonorg estrel-ethinyl estradiol,levofloxacin,enteca vir,losartan potassium/hydrochlorothiazi de,anastrozole,irbesartan,va lsartan/hydrochlorothiazide,l evothyroxine sodium,pantoprazole sodium,finasteride,amlodipin e besylate,multivit with fe,other mineral/lutein,multivitamin with minerals/folic acid,multivitamin with iron,sitagliptin phosphate/metformin hcl,multivitamin with minerals/folic acid/lycopene,multivitamin,t herapeutic,irbesartan/hydroc hlorothiazide,fenofibrate,mic ronized,sitagliptin phosphate,omeprazole,noret hindrone acetate-ethinyl estradiol/ferrous fumarate,fenofibric acid (choline),norethindrone,norg estimate-ethinyl estradiol,norethindroneethinyl estradiol/ferrous fumarate,ethinyl estradiol/drospirenone,amlo dipine besylate/benazepril hcl,azelastine hcl,letrozole,isoniazid,medro Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 73 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name m,singulair,irbesa rtanhydrochlorothiazi de,one-a-day teen advantage,januvi a,omeprazole,hyz aar,gildess fe,fenofibric acid,casodex,coz aar,levonorgestre l-eth estradiol,norethin drone,zocor,multi vital platinum,arimidex ,triprevifem,prevife m,myzilra,tenoreti c 100,tenoretic 50,tenormin,wym zya fe,drospirenoneethinyl estradiol,kurvelo, amlodipine besylatebenazepril,azelas tine hcl,all day allergy,one daily men's,one daily women's,letrozol e,senior tabs,loradamed,l evoxyl,isoniazid,s tress formula with zinc,spectravite ultra women,spectravit xyprogesterone acetate,folic acid/multivit,calcium,iron,oth er mins/lycopene/lutein,nitrogly cerin,triamterene/hydrochlor othiazide,multivitamins wminerals combination no.20/iron/folic acid,fenofibrate,multivit with min#10/folic acid//vit d3/a lipoic acid/lutein,sotalol hcl,azithromycin,exemestan e,propranolol hcl,tolterodine tartrate,multivitamin with minerals/folic acid/ginkgo leaf extract,multivits w-ca, other min/iron/folic acid/lycopene,multivit with calcium, iron, and other minerals,miconazole nitrate,multivitamins wminerals/folic acid/lycopene/ginkgo leaf xt,imiquimod,ambrisentan,a defovir dipivoxil,multivitamin with minerals/ferrous fumarat/folic acid/lutein,iron,carbonyl/folic acid/multivitamin with minerals,desogestrel-ethinyl estradiol/ethinyl estradiol,multivit,th iron,other min,tiotropium bromide,terconazole,linaglipt in,multivit,calcium,other min/ferrous fumarate/fa/lycopene/lut,mul tivitamin with minerals/folic acid/phytonadione,glatirame Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 74 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name e ultra men 50+,sharobel,pro vera,multivital,mu ltivitamins with iron,nitroglycerin patch,triamterene hydrochlorothiazi d,bacmin,complet e multivitamin,strovi te one,allertec,deblitane,micr ogestin,allerclear, one daily men's health,entecavir,s orine,azithromyci n,minastrin 24 fe,diltiazem 24hr er,lyza,aromasin, propranolol hcl er,detrol la,tiazac,nicoder m cq,one daily,centrum ultra men's,enskyce,m en's daily multivitmineral,maximum daily multivitamin,wom en's daily multivitamin,multi -vite,miconazole nitrate,miconazol e 7,gentle laxative,bisacevac,laxative suppository,wal- r acetate,thyroid,pork,estroge ns, conjugated/medroxyprogest erone acetate,febuxostat,verapami l hcl,multivitamin with min no.6/folic acid/lutein/lycop/ubidecar,m ultivit with calcium-mins/iron fumarate/folic acid/vit k,norgestrel-ethinyl estradiol,valsartan,vit b complex/vit c/folic acid/ferrous fumarate/vit e acet,multivit,therapeutic with iron/calcium/folic acid/minerals,leflunomide,m ultivitamin,therapeutic with minerals,guanfacine hcl,estrogens,esterified/met hyltestosterone,estradiol/nor ethindrone acetate,iron/liver extract/vitamin b comp and c/minerals,multivitamin with iron,hematinic,multivits wiron,hematinic,iron,carbonyl/ folic acid/multivitamin wminerals,folic acid/vitamin b comp and c,folic acid/vitamin b comp and c/zinc/vitamin d3,betaxolol hcl,paricalcitol,folic acid/multivit,calcium,iron,&ot her mins/lycopene/lutein,ezetimi be,fingolimod hcl,aliskiren hemifumarate,folic acid/multivit with fe,other Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 75 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name zyr,one daily men's 50+,one daily essential,one daily plus iron,lofibra,avalid e,imiquimod,avap ro,century,centur y energy metabolism,letairi s,wal-itin,fe c plus,jencycla,om nicap,nikki,hepse ra,exemestane,o ne daily women's 50+,one daily women's health,century ultimate men's,century ultimate women's,opurity multivitamin,mobi c,kimidess,one daily with iron,once daily,theram,vicks qlearquil allergy,magic bullet,spiriva,pimt rea,thera,astelin,t erconazole,tradje nta,taztia xt,necon,choicetabs,all day allergy relief,cartia xt,maxzide,truepl us mineral/lutein,betacarotene/ascorbic acid/vitamin e/lutein/min comb no.29,vit b complex/vit c/folic acid/ferrous sulfate/vit e acet,vit b cplx with c/ferrous fumarate/folic acid/vit d3/zinc ox,vit b comp c/ferrous fumarate/folic acid/vit e/amino acid 16,alendronate sodium,vitamin a palmitate/beta-carotene/vit d2/vit e/selenium,multivitamin with minerals/ferrous fumarate/folic acid,vitamin b comp and c/folic acid/zinc,ferrous fumarate/folic acid/vitamin b comp and c/minerals,ulipristal acetate,vismodegib,lenalido mide,ondansetron hcl,multivitamin wminerals/folic acid/co q10/lycopene/lutein,multivit, calcium,min/iron/folic acid/epigallocatechin/caff,pe g 3350/sod sulf/sod bicarbonate/sod chloride/potassium chl,multivitamin with iron and other minerals,multivitaminmins/calcium/biotin/cholecal ciferol/folic acid,ethynodiol diacetate-ethinyl estradiol,norethindrone- Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 76 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name multivitamin,deso gestr-eth estrad eth estra,a thru z select,a thru z,glatopa,naturethroid,biocel,west hroid,delyla,norlyr oc,prempro,prem phase,actos,ulori c,multi completeiron,multi-vitamin daily,verelan pm,my way,norethindron -ethinyl estradiol,marlissa ,norethin-eth estra-ferrous fum,viorele,ob complete,corvite free,lomedia 24 fe,desogen,cycle ssa,synthroid,min itran,aldara,tolter odine tartrate er,essential daily,essential woman 50+,essential man,essential man 50+,multi for her,essential balance,next choice one dose,gildagia,mo nolinyah,falmina,eli nest,men's one daily,plan b one- mestranol,calcium carbonate/cholecalciferol (vit d3)/minerals,multivitamin with iron,other min/fa/dietary supp comb. no.24,rivaroxaban,canagliflo zin Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 77 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value step,complete multi-vitmineral,complete senior,stress 500 plus zinc,valsartan,mu ltivitamins,jantove n,diabetes health formula,coumadi n,stress formula with iron,diovan,abc plus,a thru z select 50+ formula,tab-avite,tab-a-vite with iron,terazol 3,setlakin,therape utic m,leflunomide,ya z,yasmin 28,certaviteantioxidant,wome n's one daily,ultimate women's complete 50+,ultimate men's complete 50+,complete 50+,pharmacist favorite multivite,a thru z advanced formula,verapami l er pm,vitamin and minerals,biscolax ,juleber,levonorg BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 78 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value estrel,vyfemla,sol o,essentia,compa nion,thera m plus,certavite seniorantioxidant,tenex, guanfacine hcl,estrogenmethyltestosteron e,adefovir dipivoxil,tab a vite,non-drowsy allergy,allergy,nor vasc,lopreeza,zyr tec,siderol,compl ete,zithromax,tric or,procardia xl,century advanced formula,loestrin,ji nteli,loestrin fe,mircette,cardiz em la,centrum silver women,femcon fe,eliteob,dulcolax,one daily multivitaminiron,dialyvite 800,ortho micronor,cyred,di alyvite 800-ultra d,betaxolol hcl,paricalcitol,lipi tor,centralvite,microgestin fe,inderal la,fast relief laxative,estarylla, BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 79 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value triestarylla,zemplar, tilia fe,vitacel,diovan hct,sotalol,lotrel,o rtho tri-cyclen lo,diltcd,modicon,ortho novum,centravite s,femara,mens 50+ advanced one daily,complete women,zetia,dail y vitamin,complete men,trilipix,larin,d aily multiple,daily multivitaminiron,complete multi 50+,loryna,syeda, introvale,altavera, century mature,women's daily,gilenya,com plete multi,vitamin b complex,diltzac er,eemt,tekturna,t arina fe,super theravitem,arava,aubra,da ily vite with iron,daily vite,theratrum complete,daily vitamin BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 80 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value formula,daily vitamin + iron,certa plus,vitalee,adala t cc,multi-day plus iron,loestrin 24 fe,ovcon35,estrostep fe,econtra ez,nitrodur,macuvite with lutein,vitamins for hair,caziant,full spectrum b,aftera,prorenal, zenchent fe,stress formula advanced,stress formula energy,centralvite performance,des ogestrel-ethinyl estradiol,centralvite energy,lo loestrin fe,alendronate sodium,femhrt,mi mvey,gianvi,vita mins a-d-e,daily value,quintabs-m iron free,freedavite,qu in b strong,quintabsm,parvlex,monoc aps,yelets,zeosa, rena-vite,iron 100 plus,ella,multiple BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 81 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value vitamins,gildess 24 fe,nts,zarah,medr oxyprogesterone acetate,opcicon onestep,claritin,covar yx,chateal,daily vitamin formula + iron,erivedge,revli mid,ondansetron hcl,betapace,larin fe,unithroid,spect ravite,one daily for men,theragran-m premier 50 plus,spectravite ultra women's,spectra vite men's,spectravite senior,one daily diet support,trilinyah,wera,one daily for men 50+ advanced,dasetta ,men's multivitamin,philith,gol ytely,levonest,on e daily for women 50+ adv,spectravite advanced formula,daily teen multivitamin,estradiolnorethindrone acetat,spectravite BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 82 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value advanced form,miconazole 3,centrum men,junel fe 24,larin 24 fe,activella,take action,women's 50+ daily formula,men's daily formula,copaxon e,armour thyroid,norgestim ate-ethinyl estradiol,one daily womens 50 plus,briellyn,heat her,mimvey lo,hair vitamin,adults' 50+ daily formula,adults' daily formula,compete, oncovite,theradex m,jolivette,azurett e,lutera,zenchent ,reclipsen,matzim la,lowogestrel,ogestrel, biotin pluscalcium & vit d3,sronyx,quasen se,vestura,vitatru m,vitrum 50+ senior,super multivitamin,supe r multiple,layolis fe,kariva,velivet,k BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 83 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value elnor 135,aranelle,apri,a viane,enpresse,z antac,cryselle,jun el,junel fe,trilegest fe,balziva,trisprintec,portia,no rtrel,sprintec,lessi na,levora-28,trinorinyl,trinessa,br evicon,norinyl 1+35,norinyl 1+50,mononessa ,nor-q-d,generess fe,leena,ocella,jol essa,norabe,zovia 150e,zovia 135e,amethyst,triv ora-28,calcium 600+minerals,cen tral-vite select,errin,camil a,one daily maximum,cardize m cd,nephrovite,unicomplexm,super multiplelow iron,therems,ther ems-m,theremsh,spectravite adult 50+,spectravite ultra men's,central-vite men's under 50,central-vite BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 84 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value women's under 50,prilosec,cerovi te advanced formula,levaquin, xarelto,multilex-tm with minerals,multilex, central-vite women's mature,ortho tricyclen,invokana, ortho-cept,orthocyclen 01/25/2016 renvela,sevelame sevelamer carbonate r carbonate REMOVE UM: QUANTITY 17 / Day 01/25/2016 amoxicillinclavulanate potass amoxicillin/potassium clavulanate REMOVE UM: QUANTITY 8.75 / day 01/25/2016 ferosul,ferrous sulfate ferrous sulfate REMOVE UM: QUANTITY 27.273 / Day 01/25/2016 amoxicillinclavulanate potass amoxicillin/potassium clavulanate REMOVE UM: QUANTITY 4.375 / day 01/25/2016 propafenone hcl propafenone hcl REMOVE UM: QUANTITY 3.46 / day 01/25/2016 propafenone hcl,rythmol propafenone hcl REMOVE UM: QUANTITY 6.92 / day 01/25/2016 acetaminophencodeine,armour thyroid acetaminophen with codeine REMOVE UM: QUANTITY phosphate,thyroid,pork 01/25/2016 nitroglycerin,nitro nitroglycerin -time REMOVE UM: QUANTITY 11 / day 01/25/2016 ENBREL REMOVE UM: QUANTITY 0.609 / day etanercept 13 / day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 85 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/25/2016 nitronitroglycerin time,nitroglycerin REMOVE UM: QUANTITY 41 / day 01/25/2016 hydrocortisone,co hydrocortisone rtef REMOVE UM: QUANTITY 51.9 / day 01/25/2016 hydrocortisone,co hydrocortisone rtef REMOVE UM: QUANTITY 25.95 / day 01/25/2016 levothyroxine sodium,sandostat in,warfarin sodium,unithroid, coumadin,methyl prednisolone,nat urethroid,octreotide acetate,theophylli ne,synthroid,west hroid,medrol,ami odarone hcl,pacerone,levo xyl,jantoven 01/25/2016 hydrocortisone,co hydrocortisone rtef REMOVE UM: QUANTITY 103.8 / day 01/25/2016 prednisolone,prel prednisolone one REMOVE UM: QUANTITY 83.333 / day 01/27/2016 PROVENTIL HFA albuterol sulfate CHANGE TIER Covered Not Covered 01/27/2016 PROAIR HFA albuterol sulfate CHANGE TIER Covered Not Covered levothyroxine REMOVE UM: QUANTITY sodium,octreotide acetate,warfarin sodium,methylprednisolone,t hyroid,pork,theophylline anhydrous,amiodarone hcl 1.5 / day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 86 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates February, 2016 Effective Date Brand Name Generic Name Type of Change Previous Value 02/05/2016 myfortic,mycophe mycophenolate sodium nolic acid REMOVE UM: AUTHORIZATION PA applies 02/05/2016 myfortic,mycophe mycophenolate sodium nolic acid REMOVE UM: AUTHORIZATION PA applies 02/05/2016 DELZICOL mesalamine REMOVE UM: AUTHORIZATION PA applies 02/05/2016 ASACOL HD mesalamine REMOVE UM: AUTHORIZATION PA applies 02/05/2016 PENTASA mesalamine REMOVE UM: AUTHORIZATION PA applies 02/05/2016 PENTASA mesalamine REMOVE UM: AUTHORIZATION PA applies 02/05/2016 lovenox,enoxapar enoxaparin sodium in sodium CHANGE UM: CUSTOM 02/05/2016 lovenox,enoxapar enoxaparin sodium in sodium REMOVE UM: AUTHORIZATION 02/15/2016 CLARITIN loratadine REMOVE FROM FORMULARY New Value Days supplies greater than 10 DS per fill requires PA Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 87 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates March, 2016 Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 medroxyprogeste medroxyprogesterone rone acetate acetate ADD TO FORMULARY Covered 03/01/2016 depomedroxyprogesterone provera,medroxy acetate progesterone acetate ADD TO FORMULARY Covered 03/01/2016 LEVEMIR,LEVE insulin detemir MIR FLEXPEN,LEVE MIR FLEXTOUCH ADD TO FORMULARY Covered 03/01/2016 SYNTHROID levothyroxine sodium ADD TO FORMULARY Non-Formulary Covered 03/01/2016 SYNTHROID levothyroxine sodium ADD TO FORMULARY Non-Formulary Covered 03/01/2016 SYNTHROID levothyroxine sodium ADD TO FORMULARY Non-Formulary Covered 03/01/2016 SYNTHROID levothyroxine sodium ADD TO FORMULARY Non-Formulary Covered 03/01/2016 SYNTHROID levothyroxine sodium ADD TO FORMULARY Non-Formulary Covered 03/01/2016 SYNTHROID levothyroxine sodium ADD TO FORMULARY Non-Formulary Covered 03/01/2016 SYNTHROID levothyroxine sodium ADD TO FORMULARY Non-Formulary Covered 03/01/2016 SYNTHROID levothyroxine sodium ADD TO FORMULARY Non-Formulary Covered 03/01/2016 SYNTHROID levothyroxine sodium ADD TO FORMULARY Non-Formulary Covered 03/01/2016 SYNTHROID levothyroxine sodium ADD TO FORMULARY Non-Formulary Covered 03/01/2016 SYNTHROID levothyroxine sodium ADD TO FORMULARY Non-Formulary Covered 03/01/2016 SYNTHROID levothyroxine sodium ADD TO FORMULARY Non-Formulary Covered 03/01/2016 levoxyl levothyroxine sodium ADD TO FORMULARY Non-Formulary Covered 03/01/2016 LEVOXYL levothyroxine sodium ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 88 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 LEVOXYL levothyroxine sodium ADD TO FORMULARY Non-Formulary Covered 03/01/2016 LEVOXYL levothyroxine sodium ADD TO FORMULARY Non-Formulary Covered 03/01/2016 LEVOXYL levothyroxine sodium ADD TO FORMULARY Non-Formulary Covered 03/01/2016 LEVOXYL levothyroxine sodium ADD TO FORMULARY Non-Formulary Covered 03/01/2016 LEVOXYL levothyroxine sodium ADD TO FORMULARY Non-Formulary Covered 03/01/2016 LEVOXYL levothyroxine sodium ADD TO FORMULARY Non-Formulary Covered 03/01/2016 LEVOXYL levothyroxine sodium ADD TO FORMULARY Non-Formulary Covered 03/01/2016 LEVOXYL levothyroxine sodium ADD TO FORMULARY Non-Formulary Covered 03/01/2016 LEVOXYL levothyroxine sodium ADD TO FORMULARY Non-Formulary Covered 03/01/2016 medroxyprogeste medroxyprogesterone rone acetate acetate ADD UM: GENDER Female BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 89 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change 03/01/2016 fluzone pedi 20132014,fluzone 20132014,fluzone high-dose 20132014,fluzone,fluz one intradermal 20132014,flulaval quad 20142015,fluarix 20122013,flublok 20122013,flulaval 2014-2015,single use ez flu 20142015,fluarix,afluri a 20142015,fluzone 20152016,fluzone quad 20152016,fluzone high-dose 20152016,fluzone quad 20132014,fluarix 20112012,fluzone quad pedi 20132014,flublok 20132014,flucelvax,inf luenza a (h1n1) 2009,flumist,singl e use ez flu 2013- influenza virus vaccine tvs 2013-2014 (6 mos-35 mos)/pf,influenza virus vaccine tri-split 2013-14 (6 mos and older),influenza virus vaccine tvs 2013-2014 (36 mos and older)/pf,influenza virus vaccine tvs 2013-2014 (65 yr+)/pf,influenza tv-s 07-08 vaccine/pf,influenza virus vaccine tvs 2013-2014 (18 yrs-64 yrs)/pf,influenza virus vaccine quadrival 201415(36 mos & older)/pf,influenza virus vaccine tv split 2012-2013 (3 yr & older)/pf,influenza virus vaccine tv 2012-2013 (18 to 49 yrs)recomb/pf,influenza virus vaccine trivalent 201415 (36 mos and older),influenza virus vaccine trival 2014-15 (36 mos and older)/pf,influenza vaccine trival.split 2014-15 (18 yr+) cell der/pf,influenza tv-s 07-08 vaccine,influenza virus vaccine quad vs 20142015 (36 mos & older),influenza tv-s 08-09 vaccine,influenza tv-s 08-09 vaccine/pf,influenza virus vaccine trivalent 2014-2015 (5 yr & older),influenza virus vaccine trivalnt 2014-2015 (5 yr & older)/pf,influenza virus vaccine trivalent 201516 (6 mos and ADD UM: QUANTITY Previous Value New Value 1 / 270 days BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 90 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name 2014,fluzone quad pedi 20152016,flublok 20142015,fluvirin,fluari x 20142015,fluzone intradermal 20142015,fluzone quad pedi 20142015,fluarix quad 20142015,fluzone 20122013,fluzone 2011-2012 (pf),fluzone pedi 20122013,fluvirin 20142015,fluzone quad 20142015,fluzone 20142015,flulaval 20122013,flulaval 20112012,flulaval,fluz one intraderm quad 201516,physicians ez use flu 201213,fluzone intradermal 20122013,fluzone intradermal,fluzo ne highdose,fluzone older),influenza virus vaccine quadrival split 201516(36 mos+)/pf,influenza virus vaccine trivalent split 2015-2016(65 yr+)/pf,influenza virus vaccine quad vs 20132014(36 mos & older)/pf,influenza virus vaccine trivalent-split 20092010/pf,influenza virus vaccine trivalent-split 20102011/pf,influenza virus vaccine tv split 2011-2012 (3 yr & older)/pf,influenza virus vaccine quad vs 2013-2014 (6 mos-35 mos)/pf,influenza virus vaccine tv 2013-2014 (18 to 49 yrs)recomb/pf,influenza vaccine tri-splt 2012-13(18 yr +)cell derived/pf,influenza-a (h1n1) virus vaccine monovalent 2009 (live),influenza virus vaccine trivalent 2011-2012 (live),influenza virus vaccine tv live 2012-2013 (2 yrs-49 yrs),influenza virus vaccine trivalent 2009-2010 (live),influenza virus vaccine trivalent 2010-2011 (live),influenza virus vaccine tv split 2013-2014 (4 yr & older)/pf,influenza virus vaccine quadrival 2015-16 (6 mos-35 mos)/pf,influenza virus vaccine qvalsplit 20152016(6 mos and Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 91 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name high-dose 201112 (pf),fluzone 20112012,flumist quad 20142015,fluvirin 20132014,flulaval quad 20132014,ez flu 20152016 (flucelvax),fluzon e high-dose 2012-13,flumist quad 20152016,afluria 2011-2012,afluria 20122013,afluria,afluri a 2011-2012 (pf),fluarix quad 20152016,flucelvax 2014-2015,fluarix quad 20132014,ez flu 20152016 (fluvirin),agriflu,si ngle use ez flu 20122013,fluvirin 20122013,fluvirin 2011-2012,afluria 20132014,fluzone high-dose 20142015,afluria 2015- older),influenza virus vaccine tv 2014-2015(18 yrs & older)rcmb/pf,influenza virus vaccine trivalent 201415 (18 yrs-64 yrs)/pf,influenza virus vaccine quadrival 2014-15 (6 mos-35 mos)/pf,influenza vaccine tv split 2013-14 (18 yr+) cell derived/pf,influenza virus vaccine tvs 2012-2013 (36 mos and older)/pf,influenza virus vaccine tv-sp 2011-12 (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 trivalent 20142015 (4 yr & older),influenza virus vaccine trivalnt 20142015 (4 yr & older)/pf,influenza virus vaccine quadrival 20142015 (6 mos & older),influenza vacc,tri 2007(live),influenza vacc,tri 2008(live),influenza virus vaccine tri-split 20102011,influenza virus vaccine trivalent 2014-15 (6 mos and older),influenza a (h1n1) virus vaccine monovalent 2009/pf,influenza virus vaccine tri-split 20092010,influenza virus vaccine tv split 2012-2013 (18 yr & older),influenza virus Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 92 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name 2016,flulaval quad 20152016,flublok 20152016,flucelvax 20152016,fluvirin 2015-2016,fluarix 20132014,flulaval 2013-2014 vaccine tv split 2011-2012 (18 yr & older),influenza a (h1n1) virus vaccine monovalent 2009,influenza virus vaccine quadrivalent 2015-16(18yrs64yrs)/pf,influenza virus vaccine tv split 2012-2013 (4 yr & older),influenza virus vaccine tvs 2012-2013 (18 yrs-64 yrs)/pf,influenza virus vaccine trivalent-split 20112012/pf,influenza virus vaccine tv split 2011-2012 (6 mos and older),influenza vaccine quadrivalent live 2014-2015 (2 yrs-49 yrs),influenza virus vaccine tv split 2013-2014 (4 yr & older),influenza virus vaccine quad vs 2013-2014 (36 mos & older),influenza virus vaccine tv split 20122013 (6 mos and older),influenza vaccine trivalent 2015-2016(18 yr+)cell derived/pf,influenza virus vaccine trivalent-split 2012-2013 (65yr+)/pf,influenza vaccine quadrivalent live 2015-2016 (2 yrs-49 yrs),influenza virus vaccine tv split 2011-2012 (9 yr & older),influenza virus vaccine tv split 2012-2013 (5 yr & older),influenza virus vaccine tv split 2012-2013 (5 yr & older)/pf,influenza virus vaccine tv split 2011-2012 (9 Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 93 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value yr & older)/pf,influenza virus vaccine qval live 2013-2014 (2 yrs-49 yrs),influenza virus vaccine trivalnt 2015-2016 (4 yr & older)/pf,influenza virus vaccine tv split 20122013 (4 yr & older)/pf,influenza virus vaccine tv split 2011-2012 (4 yr & older),influenza virus vaccine tv split 2011-2012 (4 yr & older)/pf,influenza virus vaccine tv split 2013-2014 (5 yr & older)/pf,influenza virus vaccine trivalent 2014-2015 (65 yr+)/pf,influenza virus vaccine tv split 2013-2014 (5 yr & older),influenza virus vaccine trivalnt 2015-2016 (5 yr & older)/pf,influenza virus vaccine trivalent 20152016 (5 yr & older),influenza virus vaccine quadrival 2015-2016 (36 mos & older),influenza virus vaccine tv 2015-2016(18 yrs & older)rcmb/pf,influenza virus vaccine trivalent 20152016 (4 yr & older),influenza virus vaccine tvs 2013-2014 (36 mos and older) BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 94 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change 03/01/2016 fluzone pedi 20132014,fluzone 20132014,fluzone high-dose 20132014,fluzone,fluz one intradermal 20132014,flulaval quad 20142015,fluarix 20122013,flublok 20122013,flulaval 2014-2015,single use ez flu 20142015,fluarix,afluri a 20142015,fluzone 20152016,fluzone quad 20152016,fluzone high-dose 20152016,fluzone quad 20132014,fluarix 20112012,fluzone quad pedi 20132014,flublok 20132014,flucelvax,inf luenza a (h1n1) 2009,flumist,singl e use ez flu 2013- influenza virus vaccine tvs 2013-2014 (6 mos-35 mos)/pf,influenza virus vaccine tri-split 2013-14 (6 mos and older),influenza virus vaccine tvs 2013-2014 (36 mos and older)/pf,influenza virus vaccine tvs 2013-2014 (65 yr+)/pf,influenza tv-s 07-08 vaccine/pf,influenza virus vaccine tvs 2013-2014 (18 yrs-64 yrs)/pf,influenza virus vaccine quadrival 201415(36 mos & older)/pf,influenza virus vaccine tv split 2012-2013 (3 yr & older)/pf,influenza virus vaccine tv 2012-2013 (18 to 49 yrs)recomb/pf,influenza virus vaccine trivalent 201415 (36 mos and older),influenza virus vaccine trival 2014-15 (36 mos and older)/pf,influenza vaccine trival.split 2014-15 (18 yr+) cell der/pf,influenza tv-s 07-08 vaccine,influenza virus vaccine quad vs 20142015 (36 mos & older),influenza tv-s 08-09 vaccine,influenza tv-s 08-09 vaccine/pf,influenza virus vaccine trivalent 2014-2015 (5 yr & older),influenza virus vaccine trivalnt 2014-2015 (5 yr & older)/pf,influenza virus vaccine trivalent 201516 (6 mos and ADD TO FORMULARY Previous Value New Value Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 95 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name 2014,fluzone quad pedi 20152016,flublok 20142015,fluvirin,fluari x 20142015,fluzone intradermal 20142015,fluzone quad pedi 20142015,fluarix quad 20142015,fluzone 20122013,fluzone 2011-2012 (pf),fluzone pedi 20122013,fluvirin 20142015,fluzone quad 20142015,fluzone 20142015,flulaval 20122013,flulaval 20112012,flulaval,fluz one intraderm quad 201516,physicians ez use flu 201213,fluzone intradermal 20122013,fluzone intradermal,fluzo ne highdose,fluzone older),influenza virus vaccine quadrival split 201516(36 mos+)/pf,influenza virus vaccine trivalent split 2015-2016(65 yr+)/pf,influenza virus vaccine quad vs 20132014(36 mos & older)/pf,influenza virus vaccine trivalent-split 20092010/pf,influenza virus vaccine trivalent-split 20102011/pf,influenza virus vaccine tv split 2011-2012 (3 yr & older)/pf,influenza virus vaccine quad vs 2013-2014 (6 mos-35 mos)/pf,influenza virus vaccine tv 2013-2014 (18 to 49 yrs)recomb/pf,influenza vaccine tri-splt 2012-13(18 yr +)cell derived/pf,influenza-a (h1n1) virus vaccine monovalent 2009 (live),influenza virus vaccine trivalent 2011-2012 (live),influenza virus vaccine tv live 2012-2013 (2 yrs-49 yrs),influenza virus vaccine trivalent 2009-2010 (live),influenza virus vaccine trivalent 2010-2011 (live),influenza virus vaccine tv split 2013-2014 (4 yr & older)/pf,influenza virus vaccine quadrival 2015-16 (6 mos-35 mos)/pf,influenza virus vaccine qvalsplit 20152016(6 mos and Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 96 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name high-dose 201112 (pf),fluzone 20112012,flumist quad 20142015,fluvirin 20132014,flulaval quad 20132014,ez flu 20152016 (flucelvax),fluzon e high-dose 2012-13,flumist quad 20152016,afluria 2011-2012,afluria 20122013,afluria,afluri a 2011-2012 (pf),fluarix quad 20152016,flucelvax 2014-2015,fluarix quad 20132014,ez flu 20152016 (fluvirin),agriflu,si ngle use ez flu 20122013,fluvirin 20122013,fluvirin 2011-2012,afluria 20132014,fluzone high-dose 20142015,afluria 2015- older),influenza virus vaccine tv 2014-2015(18 yrs & older)rcmb/pf,influenza virus vaccine trivalent 201415 (18 yrs-64 yrs)/pf,influenza virus vaccine quadrival 2014-15 (6 mos-35 mos)/pf,influenza vaccine tv split 2013-14 (18 yr+) cell derived/pf,influenza virus vaccine tvs 2012-2013 (36 mos and older)/pf,influenza virus vaccine tv-sp 2011-12 (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 trivalent 20142015 (4 yr & older),influenza virus vaccine trivalnt 20142015 (4 yr & older)/pf,influenza virus vaccine quadrival 20142015 (6 mos & older),influenza vacc,tri 2007(live),influenza vacc,tri 2008(live),influenza virus vaccine tri-split 20102011,influenza virus vaccine trivalent 2014-15 (6 mos and older),influenza a (h1n1) virus vaccine monovalent 2009/pf,influenza virus vaccine tri-split 20092010,influenza virus vaccine tv split 2012-2013 (18 yr & older),influenza virus Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 97 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name 2016,flulaval quad 20152016,flublok 20152016,flucelvax 20152016,fluvirin 2015-2016,fluarix 20132014,flulaval 2013-2014 vaccine tv split 2011-2012 (18 yr & older),influenza a (h1n1) virus vaccine monovalent 2009,influenza virus vaccine quadrivalent 2015-16(18yrs64yrs)/pf,influenza virus vaccine tv split 2012-2013 (4 yr & older),influenza virus vaccine tvs 2012-2013 (18 yrs-64 yrs)/pf,influenza virus vaccine trivalent-split 20112012/pf,influenza virus vaccine tv split 2011-2012 (6 mos and older),influenza vaccine quadrivalent live 2014-2015 (2 yrs-49 yrs),influenza virus vaccine tv split 2013-2014 (4 yr & older),influenza virus vaccine quad vs 2013-2014 (36 mos & older),influenza virus vaccine tv split 20122013 (6 mos and older),influenza vaccine trivalent 2015-2016(18 yr+)cell derived/pf,influenza virus vaccine trivalent-split 2012-2013 (65yr+)/pf,influenza vaccine quadrivalent live 2015-2016 (2 yrs-49 yrs),influenza virus vaccine tv split 2011-2012 (9 yr & older),influenza virus vaccine tv split 2012-2013 (5 yr & older),influenza virus vaccine tv split 2012-2013 (5 yr & older)/pf,influenza virus vaccine tv split 2011-2012 (9 Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 98 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value yr & older)/pf,influenza virus vaccine qval live 2013-2014 (2 yrs-49 yrs),influenza virus vaccine trivalnt 2015-2016 (4 yr & older)/pf,influenza virus vaccine tv split 20122013 (4 yr & older)/pf,influenza virus vaccine tv split 2011-2012 (4 yr & older),influenza virus vaccine tv split 2011-2012 (4 yr & older)/pf,influenza virus vaccine tv split 2013-2014 (5 yr & older)/pf,influenza virus vaccine trivalent 2014-2015 (65 yr+)/pf,influenza virus vaccine tv split 2013-2014 (5 yr & older),influenza virus vaccine trivalnt 2015-2016 (5 yr & older)/pf,influenza virus vaccine trivalent 20152016 (5 yr & older),influenza virus vaccine quadrival 2015-2016 (36 mos & older),influenza virus vaccine tv 2015-2016(18 yrs & older)rcmb/pf,influenza virus vaccine trivalent 20152016 (4 yr & older),influenza virus vaccine tvs 2013-2014 (36 mos and older) 03/01/2016 fluvastatin sodium,lescol fluvastatin sodium ADD UM: QUANTITY 03/01/2016 LESCOL fluvastatin sodium ADD TO FORMULARY 03/01/2016 fluvastatin sodium,lescol fluvastatin sodium ADD UM: QUANTITY 1 / Day Non-Formulary Covered 2 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 99 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 aspirin ec,adult aspirin low dose aspirin ec,aspir-low,low dose aspirin ec,ecotrin,lo-dose aspirin ec,miniprin,aspir 81,st. joseph aspirin ADD UM: QUANTITY 1 / Day 03/01/2016 enalapril enalapril maleate maleate,vasotec ADD UM: QUANTITY 1.5 / day 03/01/2016 enalapril enalapril maleate maleate,vasotec ADD UM: QUANTITY 1.5 / day 03/01/2016 enalapril enalapril maleate maleate,vasotec ADD UM: QUANTITY 2 / Day 03/01/2016 enalapril enalapril maleate maleate,vasotec ADD UM: QUANTITY 1.5 / day 03/01/2016 ursodiol,actigall ADD UM: QUANTITY 5 / Day 03/01/2016 nasacort triamcinolone acetonide aq,triamcinolone acetonide ADD UM: QUANTITY 1.1 / day 03/01/2016 hydralazine hcl hydralazine hcl ADD UM: QUANTITY 3 / Day 03/01/2016 hydralazine hcl hydralazine hcl ADD UM: QUANTITY 3 / Day 03/01/2016 hydralazine hcl hydralazine hcl ADD UM: QUANTITY 4 / Day 03/01/2016 hydralazine hcl hydralazine hcl ADD UM: QUANTITY 3 / Day 03/01/2016 prazosin hcl,minipress prazosin hcl ADD UM: QUANTITY 2 / Day 03/01/2016 prazosin hcl,minipress prazosin hcl ADD UM: QUANTITY 2 / Day 03/01/2016 prazosin hcl,minipress prazosin hcl ADD UM: QUANTITY 2 / Day ursodiol BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 100 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 lansoprazole,hea lansoprazole rtburn relief 24 hour,heartburn treatment 24 hour,prevacid 24hr,prevacid ADD UM: QUANTITY 1 / Day 03/01/2016 lansoprazole,prev lansoprazole acid ADD UM: QUANTITY 1 / Day 03/01/2016 nitroglycerin patch,nitrodur,minitran nitroglycerin ADD UM: QUANTITY 1 / Day 03/01/2016 nitroglycerin nitroglycerin patch,minitran,nit ro-dur ADD UM: QUANTITY 1 / Day 03/01/2016 nitroglycerin patch,nitrodur,minitran nitroglycerin ADD UM: QUANTITY 1 / Day 03/01/2016 nitrodur,nitroglycerin patch,minitran nitroglycerin ADD UM: QUANTITY 1 / Day 03/01/2016 calcitrene,calcipo calcipotriene triene ADD UM: QUANTITY 2 / Day 03/01/2016 dovonex,calcipotr calcipotriene iene ADD UM: QUANTITY 2 / Day 03/01/2016 nifedipine er,nifedical xl,procardia xl nifedipine ADD UM: QUANTITY 1 / Day 03/01/2016 nifedical xl,nifedipine er,procardia xl nifedipine ADD UM: QUANTITY 1 / Day 03/01/2016 nifedipine er,procardia xl nifedipine ADD UM: QUANTITY 1 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 101 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 nifedipine er,adalat cc,afeditab cr nifedipine ADD UM: QUANTITY 1 / Day 03/01/2016 adalat cc,nifedipine er,afeditab cr nifedipine ADD UM: QUANTITY 1 / Day 03/01/2016 adalat cc,nifedipine er nifedipine ADD UM: QUANTITY 1 / Day 03/01/2016 acarbose,precos acarbose e ADD UM: QUANTITY 4 / Day 03/01/2016 acarbose,precos acarbose e ADD UM: QUANTITY 3 / Day 03/01/2016 diltiazem 24hr diltiazem hcl cd,diltcd,diltiazem 24hr er,cardizem cd,cartia xt ADD UM: QUANTITY 1 / Day 03/01/2016 diltiazem 24hr diltiazem hcl er,diltiazem 24hr cd,diltcd,cardizem cd,cartia xt ADD UM: QUANTITY 1 / Day 03/01/2016 diltiazem 24hr diltiazem hcl er,diltiazem 24hr cd,diltcd,cardizem cd,cartia xt ADD UM: QUANTITY 1 / Day 03/01/2016 diltiazem 24hr diltiazem hcl cd,cardizem cd,diltiazem 24hr er,dilt-cd,cartia xt ADD UM: QUANTITY 1 / Day 03/01/2016 tiazac,taztia xt,diltiazem er,diltzac er ADD UM: QUANTITY 1 / Day diltiazem hcl BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 102 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 diltzac diltiazem hcl er,diltiazem er,tiazac,taztia xt ADD UM: QUANTITY 1 / Day 03/01/2016 diltzac er,tiazac,diltiaze m er,taztia xt diltiazem hcl ADD UM: QUANTITY 1 / Day 03/01/2016 diltzac diltiazem hcl er,diltiazem er,tiazac,taztia xt ADD UM: QUANTITY 1 / Day 03/01/2016 diltzac er,tiazac,diltiaze m er,taztia xt ADD UM: QUANTITY 1 / Day 03/01/2016 nifedipine,procar nifedipine dia ADD UM: QUANTITY 4 / Day 03/01/2016 nifedipine nifedipine ADD UM: QUANTITY 4 / Day 03/01/2016 diltiazem hcl,cardizem diltiazem hcl ADD UM: QUANTITY 1 / Day 03/01/2016 diltiazem hcl,cardizem diltiazem hcl ADD UM: QUANTITY 1 / Day 03/01/2016 diltiazem hcl,cardizem diltiazem hcl ADD UM: QUANTITY 4 / Day 03/01/2016 diltiazem hcl,cardizem diltiazem hcl ADD UM: QUANTITY 1 / Day 03/01/2016 nicardipine hcl nicardipine hcl ADD UM: QUANTITY 1 / Day 03/01/2016 nicardipine hcl nicardipine hcl ADD UM: QUANTITY 1 / Day 03/01/2016 nimodipine nimodipine ADD UM: QUANTITY 1 / Day 03/01/2016 isradipine isradipine ADD UM: QUANTITY 2 / Day 03/01/2016 isradipine isradipine ADD UM: QUANTITY 2 / Day 03/01/2016 felodipine er felodipine ADD UM: QUANTITY 1 / Day diltiazem hcl BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 103 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 felodipine er felodipine ADD UM: QUANTITY 1 / Day 03/01/2016 felodipine er felodipine ADD UM: QUANTITY 2 / Day 03/01/2016 amlodipine amlodipine besylate besylate,norvasc ADD UM: QUANTITY 1 / Day 03/01/2016 norvasc,amlodipi amlodipine besylate ne besylate ADD UM: QUANTITY 1 / Day 03/01/2016 amlodipine amlodipine besylate besylate,norvasc ADD UM: QUANTITY 1 / Day 03/01/2016 verelan,verapamil verapamil hcl sr,verapamil er ADD UM: QUANTITY 2 / Day 03/01/2016 verelan,verapamil verapamil hcl sr,verapamil er ADD UM: QUANTITY 1 / Day 03/01/2016 verelan,verapamil verapamil hcl sr,verapamil er ADD UM: QUANTITY 2 / Day 03/01/2016 verelan,verapamil verapamil hcl sr,verapamil er ADD UM: QUANTITY 1 / Day 03/01/2016 verelan,verapamil verapamil hcl sr,verapamil er ADD UM: QUANTITY 2 / Day 03/01/2016 verelan,verapamil verapamil hcl sr,verapamil er ADD UM: QUANTITY 1 / Day 03/01/2016 nicotine nicotine polacrilex gum,nicorette,nic orelief,quit 2 ADD UM: QUANTITY 30 / Day 03/01/2016 nicotine gum,quit nicotine polacrilex 4,nicorette,nicorel ief ADD UM: QUANTITY 24 / day 03/01/2016 inderal propranolol hcl la,propranolol hcl er ADD UM: QUANTITY 3 / Day 03/01/2016 propranolol hcl er,inderal la ADD UM: QUANTITY 2 / Day propranolol hcl BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 104 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 propranolol hcl er,inderal la propranolol hcl ADD UM: QUANTITY 2 / Day 03/01/2016 propranolol hcl er,inderal la propranolol hcl ADD UM: QUANTITY 4 / Day 03/01/2016 memantine hcl,namenda memantine hcl ADD UM: QUANTITY 2 / Day 03/01/2016 nicotine patch,nicoderm cq nicotine ADD UM: QUANTITY 1 / Day 03/01/2016 nicotine patch,nicoderm cq nicotine ADD UM: QUANTITY 1 / Day 03/01/2016 nicotine patch,nicoderm cq,nts nicotine ADD UM: QUANTITY 1 / Day 03/01/2016 NICOTROL NS nicotine ADD UM: QUANTITY 0.533 / day 03/01/2016 donepezil hcl,aricept donepezil hcl ADD UM: QUANTITY 2 / Day 03/01/2016 aricept,donepezil donepezil hcl hcl ADD UM: QUANTITY 1 / Day 03/01/2016 omeprazole,prilos omeprazole ec ADD UM: QUANTITY 2 / Day 03/01/2016 irbesartan,avapro irbesartan ADD UM: QUANTITY 1 / Day 03/01/2016 irbesartan,avapro irbesartan ADD UM: QUANTITY 1 / Day 03/01/2016 irbesartan,avapro irbesartan ADD UM: QUANTITY 1 / Day 03/01/2016 HUMALOG ADD UM: QUANTITY 0.667 / day 03/01/2016 imitrex,sumatripta sumatriptan succinate n succinate ADD UM: QUANTITY 0.3 / day 03/01/2016 sumatriptan sumatriptan succinate succinate,imitrex ADD UM: QUANTITY 0.3 / day insulin lispro BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 105 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 sumatriptan sumatriptan succinate succinate,imitrex ADD UM: QUANTITY 0.3 / day 03/01/2016 glyburide,diabeta glyburide ADD UM: QUANTITY 4 / Day 03/01/2016 glyburide,diabeta glyburide ADD UM: QUANTITY 4 / Day 03/01/2016 glyburide,diabeta glyburide ADD UM: QUANTITY 4 / Day 03/01/2016 glyburide glyburide,micronized micronized,glyna se ADD UM: QUANTITY 1 / Day 03/01/2016 glyburide glyburide,micronized micronized,glyna se ADD UM: QUANTITY 1 / Day 03/01/2016 glyburide glyburide,micronized micronized,glyna se ADD UM: CUSTOM Cumulative: 9/30 day across oral triptans 03/01/2016 glyburide glyburide,micronized micronized,glyna se ADD UM: QUANTITY 1 / Day 03/01/2016 glyburide glyburide,micronized micronized,glyna se ADD UM: CUSTOM Cumulative: 9/30 day across oral triptans 03/01/2016 diabinese,chlorpr chlorpropamide opamide ADD UM: CUSTOM Cumulative: 9/30 day across oral triptans 03/01/2016 chlorpropamide chlorpropamide ADD UM: QUANTITY 4 / Day 03/01/2016 chlorpropamide chlorpropamide ADD UM: QUANTITY 3 / Day 03/01/2016 glimepiride,amary glimepiride l ADD UM: QUANTITY 2 / Day 03/01/2016 glimepiride,amary glimepiride l ADD UM: QUANTITY 2 / Day 03/01/2016 glimepiride,amary glimepiride l ADD UM: QUANTITY 2 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 106 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 lidocaineprilocaine,emla lidocaine/prilocaine ADD UM: QUANTITY 1 / Day 03/01/2016 granisetron hcl granisetron hcl ADD UM: QUANTITY 0.133 / day 03/01/2016 elocon,mometaso mometasone furoate ne furoate ADD UM: QUANTITY 2 / Day 03/01/2016 allopurinol,zylopri allopurinol m ADD UM: QUANTITY 1 / Day 03/01/2016 allopurinol,zylopri allopurinol m ADD UM: QUANTITY 1 / Day 03/01/2016 tramadol hcl,ultram tramadol hcl ADD UM: QUANTITY 4 / Day 03/01/2016 indapamide indapamide ADD UM: QUANTITY 1 / Day 03/01/2016 indapamide indapamide ADD UM: QUANTITY 1 / Day 03/01/2016 dilt-xr,diltia xt,diltiazem er diltiazem hcl ADD UM: QUANTITY 1 / Day 03/01/2016 diltiazem er,diltia diltiazem hcl xt,dilt-xr,dilacor xr ADD UM: QUANTITY 1 / Day 03/01/2016 diltia xt,diltxr,diltiazem er diltiazem hcl ADD UM: QUANTITY 1 / Day 03/01/2016 sodium fluoride sodium fluoride ADD UM: QUANTITY 2 / Day 03/01/2016 fluoride,ludent sodium fluoride fluoride,fluoritab,s odium fluoride ADD UM: QUANTITY 1 / Day 03/01/2016 ludent sodium fluoride fluoride,fluoride,fl uoritab,sodium fluoride ADD UM: QUANTITY 1 / Day 03/01/2016 clotrimazole clotrimazole ADD UM: QUANTITY 5 / Day 03/01/2016 NICOTROL nicotine ADD UM: QUANTITY 0.034 / day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 107 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 acarbose,precos acarbose e ADD UM: QUANTITY 3 / Day 03/01/2016 sucralfate,carafat sucralfate e ADD UM: QUANTITY 4 / Day 03/01/2016 misoprostol,cytot misoprostol ec ADD UM: QUANTITY 4 / Day 03/01/2016 cytotec,misoprost misoprostol ol ADD UM: QUANTITY 4 / Day 03/01/2016 cilostazol,pletal cilostazol ADD UM: QUANTITY 2 / Day 03/01/2016 cilostazol,pletal cilostazol ADD UM: QUANTITY 2 / Day 03/01/2016 bisacodyl,laxative bisacodyl suppository,gentl e laxative,dulcolax, magic bullet,biscolax,fas t relief laxative,bisacevac ADD UM: QUANTITY 1 / Day 03/01/2016 trospium trospium chloride chloride,sanctura ADD UM: QUANTITY 2 / Day 03/01/2016 dulcolax,bisacody bisacodyl l,laxative,gentle laxative,ducodyl, women's laxative,women's gentle laxative,woman's laxative,alophen pills,bisa-lax ADD UM: QUANTITY 1 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 108 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 stool docusate sodium softener,docusat e sodium,docusil,d ocu soft,dok,colrite,doc-qlace,colace,wom ens stool softener,dulcolax stool softener,phillips' laxative,sof-lax ADD UM: QUANTITY 1 / Day 03/01/2016 metformin hcl,glucophage metformin hcl ADD UM: QUANTITY 2 / Day 03/01/2016 metformin hcl,glucophage metformin hcl ADD UM: QUANTITY 2 / Day 03/01/2016 glipizide,glucotrol glipizide ADD UM: QUANTITY 8 / Day 03/01/2016 glipizide,glucotrol glipizide ADD UM: QUANTITY 4 / Day 03/01/2016 glipizide xl,glipizide er,glucotrol xl glipizide ADD UM: QUANTITY 2 / Day 03/01/2016 glipizide er,glipizide xl,glucotrol xl glipizide ADD UM: QUANTITY 2 / Day 03/01/2016 metformin hcl,glucophage metformin hcl ADD UM: QUANTITY 2 / Day 03/01/2016 PREMARIN estrogens, conjugated ADD UM: QUANTITY 1 / Day 03/01/2016 PREMARIN estrogens, conjugated ADD UM: QUANTITY 1 / Day 03/01/2016 PREMARIN estrogens, conjugated ADD UM: QUANTITY 1 / Day 03/01/2016 PREMARIN estrogens, conjugated ADD UM: QUANTITY 1 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 109 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 avalide,irbesartan irbesartan/hydrochlorothiazi de hydrochlorothiazi de ADD UM: QUANTITY 1 / Day 03/01/2016 prenatal 11,prenatal z,vynatalfa,mynatal plus,lactocalf,mynatalz,prenatal plus prenatal vitamins/ferrous fumarate/folic acid,prenatal vitamins with calcium/ferrous fumarate/folic acid ADD UM: QUANTITY 1 / Day 03/01/2016 O-CAL FA prenatal vitamins with calcium/ferrous fumarate/folic acid ADD UM: QUANTITY 1 / Day 03/01/2016 right step prenatal vitamins,prenatal, prenatal s,prenatal vitamins prenatal vitamins with calcium/ferrous fumarate/folic acid,prenatal vitamins/ferrous fumarate/folic acid,prenatal vitamins/ferrous sulfate/folic acid,prenatal vits wca,fe,fa(<1mg) ADD UM: QUANTITY 1 / Day 03/01/2016 prenatal mr 90 fe,se-natal 90,mynate 90 plus prenatal vitamins/ferrous fumarate/docusate/folic acid,prenatal vitamins with calcium/ferrous fumarate/docusate/fa ADD UM: QUANTITY 1 / Day 03/01/2016 depomedroxyprogesterone provera,medroxy acetate progesterone acetate ADD UM: QUANTITY 1 / 270 Days 03/01/2016 depomedroxyprogesterone provera,medroxy acetate progesterone acetate ADD UM: QUANTITY 1 / 270 Days BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 110 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 norethindrone norethindrone acetate acetate,aygestin ADD UM: QUANTITY 2 / Day 03/01/2016 irbesartanirbesartan/hydrochlorothiazi hydrochlorothiazi de de,avalide ADD UM: QUANTITY 1 / Day 03/01/2016 HUMULIN R,NOVOLIN R insulin regular, human ADD UM: QUANTITY 2 / Day 03/01/2016 HUMULIN N,NOVOLIN N insulin nph human isophane,nph, human insulin isophane ADD UM: QUANTITY 2 / Day 03/01/2016 ranitidine hcl ranitidine hcl ADD UM: QUANTITY 10 / day 03/01/2016 tolterodine tartrate er,detrol la tolterodine tartrate ADD UM: QUANTITY 1 / Day 03/01/2016 tolterodine tartrate er,detrol la tolterodine tartrate ADD UM: QUANTITY 1 / Day 03/01/2016 starlix,nateglinide nateglinide ADD UM: QUANTITY 3 / Day 03/01/2016 alendronate sodium ADD UM: QUANTITY 0.133 / day 03/01/2016 norco,hydrocodo hydrocodone nebitartrate/acetaminophen acetaminophen,lo rtab,lorcet ADD UM: QUANTITY 4 / Day 03/01/2016 hydrocodonehydrocodone acetaminophen,lo bitartrate/acetaminophen rtab,lorcet plus,norco ADD UM: QUANTITY 4 / Day 03/01/2016 fenofibrate,lofibra fenofibrate ADD UM: QUANTITY 1 / Day 03/01/2016 metoprolol succinate,toprol xl ADD UM: QUANTITY 1.5 / day alendronate sodium metoprolol succinate BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 111 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 LANTUS insulin glargine,human recombinant analog,insulin glargine, human recombinant analog ADD UM: QUANTITY 2 / Day 03/01/2016 valganciclovir hcl,valcyte valganciclovir hcl ADD UM: QUANTITY 2 / Day 03/01/2016 fenofibrate,lofibra fenofibrate ADD UM: QUANTITY 1 / Day 03/01/2016 prenatal vitamins,prenatal formula,stuart prenatal,prenatal prenatal vits wca,fe,fa(<1mg),prenatal vitamins with calcium/ferrous fumarate/folic acid,prenatal vitamins/ferrous fumarate/folic acid ADD UM: CUSTOM Cumulative: MED 200mg/day 03/01/2016 prenatal vitamins,prenatal formula,stuart prenatal,prenatal prenatal vits wca,fe,fa(<1mg),prenatal vitamins with calcium/ferrous fumarate/folic acid,prenatal vitamins/ferrous fumarate/folic acid ADD UM: QUANTITY 1 / Day 03/01/2016 ipratropiumipratropium albuterol,duoneb bromide/albuterol sulfate ADD UM: CUSTOM Cumulative: MED 200mg/day 03/01/2016 ipratropiumipratropium albuterol,duoneb bromide/albuterol sulfate ADD UM: QUANTITY 3 / Day 03/01/2016 nasal decon pseudoephedrine hcl (pseudoephedrin e),pseudoephedri ne hcl ADD UM: QUANTITY 10 / day 03/01/2016 acyclovir,zovirax acyclovir ADD UM: QUANTITY 1 / Day 03/01/2016 acyclovir,zovirax acyclovir ADD UM: QUANTITY 2 / Day 03/01/2016 valacyclovir,valtre valacyclovir hcl x ADD UM: QUANTITY 2 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 112 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 valacyclovir,valtre valacyclovir hcl x ADD UM: QUANTITY 1 / Day 03/01/2016 perindopril erbumine perindopril erbumine ADD UM: QUANTITY 1.5 / day 03/01/2016 perindopril erbumine,aceon perindopril erbumine ADD UM: QUANTITY 1.5 / day 03/01/2016 ofloxacin ofloxacin ADD UM: QUANTITY 0.167 / day 03/01/2016 cyclosporine,san cyclosporine dimmune ADD UM: QUANTITY 5 / Day 03/01/2016 sandimmune,cycl cyclosporine osporine ADD UM: QUANTITY 16 / Day 03/01/2016 gengraf,cyclospor cyclosporine, modified ine modified,neoral ADD UM: QUANTITY 1 / Day 03/01/2016 neoral,cyclospori cyclosporine, modified ne modified,gengraf ADD UM: QUANTITY 1 / Day 03/01/2016 famciclovir,famvir famciclovir ADD UM: QUANTITY 3 / Day 03/01/2016 famciclovir,famvir famciclovir ADD UM: QUANTITY 3 / Day 03/01/2016 famciclovir,famvir famciclovir ADD UM: QUANTITY 3 / Day 03/01/2016 cholestyramine,q cholestyramine (with sugar) uestran ADD UM: QUANTITY 1 / Day 03/01/2016 zolmitriptan odt,zomig zmt zolmitriptan ADD UM: QUANTITY 0.3 / day 03/01/2016 FORTEO teriparatide ADD UM: QUANTITY 0.034 / day 03/01/2016 XARELTO rivaroxaban ADD UM: QUANTITY 1 / Day 03/01/2016 albuterol sulfate,accuneb albuterol sulfate ADD UM: QUANTITY 7.5 / day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 113 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name 03/01/2016 albuterol sulfate,accuneb 03/01/2016 Generic Name albuterol sulfate Type of Change Previous Value New Value ADD UM: QUANTITY 7.5 / day nicotine nicotine polacrilex lozenge,nicorette, stop smoking aid,quit 4 ADD UM: QUANTITY 20 / Day 03/01/2016 nicotine nicotine polacrilex lozenge,nicorette, stop smoking aid,quit 2 ADD UM: QUANTITY 30 / Day 03/01/2016 nicotine nicotine polacrilex lozenge,nicorette, stop smoking aid,quit 2 ADD UM: QUANTITY 20 / Day 03/01/2016 nicotine nicotine polacrilex lozenge,nicorette, commit,nicorelief, stop smoking aid,quit 2 ADD UM: CUSTOM Cumulative: 9/30 day across oral triptans 03/01/2016 compazine,prochl prochlorperazine orperazine,compr o ADD UM: QUANTITY 2 / Day 03/01/2016 prochlorperazine prochlorperazine maleate maleate,compazi ne ADD UM: QUANTITY 1 / Day 03/01/2016 prochlorperazine prochlorperazine maleate maleate,compazi ne ADD UM: QUANTITY 1 / Day 03/01/2016 losartan losartan potassium potassium,cozaar ADD UM: QUANTITY 1 / Day 03/01/2016 losartan losartan potassium potassium,cozaar ADD UM: QUANTITY 1 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 114 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 losartanlosartan hydrochlorothiazi potassium/hydrochlorothiazi de,hyzaar de ADD UM: QUANTITY 1 / Day 03/01/2016 losartan losartan potassium potassium,cozaar ADD UM: QUANTITY 1 / Day 03/01/2016 losartanlosartan hydrochlorothiazi potassium/hydrochlorothiazi de,hyzaar de ADD UM: QUANTITY 1 / Day 03/01/2016 oxycodoneoxycodone acetaminophen,e hcl/acetaminophen ndocet,percocet ADD UM: QUANTITY 4 / Day 03/01/2016 TRACLEER bosentan ADD UM: QUANTITY 2 / Day 03/01/2016 TRACLEER bosentan ADD UM: QUANTITY 2 / Day 03/01/2016 ELIDEL pimecrolimus ADD UM: QUANTITY 1 / Day 03/01/2016 pravastatin pravastatin sodium sodium,pravachol ADD UM: QUANTITY 1 / Day 03/01/2016 ortho evra,xulane norelgestromin/ethinyl estradiol ADD UM: QUANTITY 0.143 / day 03/01/2016 femhrt,norethindr norethindrone acetateon-ethinyl ethinyl estradiol estradiol,jevantiq ue lo ADD UM: QUANTITY 1 / Day 03/01/2016 selegiline hcl,eldepryl ADD UM: QUANTITY 2 / Day 03/01/2016 eldepryl,selegilin selegiline hcl e hcl ADD UM: CUSTOM Cumulative: MED 200mg/day + 4 gm/day Acetamin. 03/01/2016 cormax,clobetaso clobetasol propionate l propionate,temov ate ADD UM: QUANTITY 1.67 / day selegiline hcl BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 115 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 meperidine hcl meperidine hcl ADD UM: QUANTITY 10 / day 03/01/2016 meperidine hcl,demerol meperidine hcl ADD UM: QUANTITY 1 / Day 03/01/2016 meperidine hcl,demerol meperidine hcl ADD UM: QUANTITY 1 / Day 03/01/2016 morphine sulfate morphine sulfate ADD UM: QUANTITY 8 / Day 03/01/2016 morphine sulfate morphine sulfate ADD UM: QUANTITY 8 / Day 03/01/2016 morphine sulfate morphine sulfate ADD UM: QUANTITY 8 / Day 03/01/2016 morphine sulfate morphine sulfate ADD UM: QUANTITY 4 / Day 03/01/2016 morphine sulfate morphine sulfate ADD UM: CUSTOM Cumulative: MED 200mg/day 03/01/2016 morphine sulfate morphine sulfate ADD UM: QUANTITY 4 / Day 03/01/2016 morphine sulfate morphine sulfate er,ms contin ADD UM: QUANTITY 2 / Day 03/01/2016 morphine sulfate morphine sulfate er,morphine sulfate,ms contin ADD UM: CUSTOM Cumulative: MED 200mg/day 03/01/2016 trilipix,fenofibric acid fenofibric acid (choline) ADD UM: QUANTITY 1 / Day 03/01/2016 trilipix,fenofibric acid fenofibric acid (choline) ADD UM: CUSTOM Cumulative: MED 200mg/day 03/01/2016 fenofibric acid,trilipix fenofibric acid (choline) ADD UM: CUSTOM Cumulative: MED 200mg/day 03/01/2016 fenofibric acid,trilipix fenofibric acid (choline) ADD UM: QUANTITY 1 / Day 03/01/2016 hydromorphone hcl,dilaudid hydromorphone hcl ADD UM: CUSTOM Cumulative: MED 200mg/day 03/01/2016 dilaudid,hydromo hydromorphone hcl rphone hcl ADD UM: QUANTITY 4 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 116 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 hydromorphone hcl,dilaudid hydromorphone hcl ADD UM: QUANTITY 4 / Day 03/01/2016 hydromorphone hcl,dilaudid hydromorphone hcl ADD UM: CUSTOM Cumulative: MED 200mg/day 03/01/2016 codeine sulfate codeine sulfate ADD UM: QUANTITY 3 / Day 03/01/2016 codeine sulfate codeine sulfate ADD UM: CUSTOM Cumulative: MED 200mg/day 03/01/2016 codeine sulfate codeine sulfate ADD UM: QUANTITY 3 / Day 03/01/2016 codeine sulfate codeine sulfate ADD UM: CUSTOM Cumulative: MED 200mg/day 03/01/2016 codeine sulfate codeine sulfate ADD UM: CUSTOM Cumulative: MED 200mg/day 03/01/2016 codeine sulfate codeine sulfate ADD UM: QUANTITY 3 / Day 03/01/2016 oxycodone hcl,roxicodone oxycodone hcl ADD UM: QUANTITY 4 / Day 03/01/2016 methadone hcl methadone hcl ADD UM: QUANTITY 30 / Day 03/01/2016 methadone hcl methadone hcl ADD UM: QUANTITY 20 / Day 03/01/2016 methadone hcl methadone hcl ADD UM: CUSTOM Cumulative: MED 200mg/day 03/01/2016 methadone methadone hcl hcl,methadone intensol,methado se ADD UM: QUANTITY 8 / Day 03/01/2016 methadone methadone hcl intensol,methado ne hcl,methadose ADD UM: CUSTOM Cumulative: MED 200mg/day 03/01/2016 methadone methadone hcl hcl,methadose,do lophine hcl ADD UM: QUANTITY 4 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 117 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 methadone methadone hcl hcl,dolophine hcl ADD UM: QUANTITY 4 / Day 03/01/2016 morphine sulfate morphine sulfate er,ms contin ADD UM: QUANTITY 2 / Day 03/01/2016 morphine sulfate morphine sulfate er,morphine sulfate,oramorph sr,ms contin,morphine sulfate cr ADD UM: CUSTOM Cumulative: MED 200mg/day 03/01/2016 morphine sulfate morphine sulfate er,ms contin ADD UM: QUANTITY 2 / Day 03/01/2016 morphine sulfate morphine sulfate er,morphine sulfate,morphine sulfate cr,oramorph sr,ms contin ADD UM: CUSTOM Cumulative: MED 200mg/day 03/01/2016 morphine sulfate morphine sulfate er,ms contin ADD UM: QUANTITY 2 / Day 03/01/2016 morphine sulfate morphine sulfate er,ms contin ADD UM: QUANTITY 2 / Day 03/01/2016 morphine morphine sulfate sulfate,morphine sulfate er,oramorph sr,ms contin,morphine sulfate cr ADD UM: CUSTOM Cumulative: MED 200mg/day 03/01/2016 aspirin,lite coat aspirin ADD UM: QUANTITY 1 / Day aspirin BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 118 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 aspirin,lite coat aspirin aspirin,st. joseph aspirin,analgesic, bayer aspirin ADD UM: CUSTOM Cumulative: MED 200mg/day 03/01/2016 children's aspirin aspirin,aspirin,st. joseph aspirin,baby aspirin,st joseph aspirin,bayer chewable aspirin ADD UM: CUSTOM Cumulative: MED 200mg/day 03/01/2016 aspirin,children's aspirin aspirin,st. joseph aspirin,bayer chewable aspirin ADD UM: QUANTITY 1 / Day 03/01/2016 aspirin ec,aspir- aspirin trin,ecotrin,ecpirin ,genacote ADD UM: CUSTOM Cumulative: MED 200mg/day 03/01/2016 aspirin ec,aspir- aspirin trin,ecotrin,ecpirin ADD UM: QUANTITY 1 / Day 03/01/2016 ULORIC febuxostat ADD UM: CUSTOM Cumulative: MED 200mg/day 03/01/2016 ULORIC febuxostat ADD UM: QUANTITY 1 / Day 03/01/2016 fever acetaminophen reducer,acetamin ophen,feverall,ac ephen,children's fever reducing,children' s nonaspirin,children's fever reducer,child pain rel-fever reducer ADD UM: QUANTITY 4 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 119 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 children's fever acetaminophen reducer,acephen, feverall,acetamin ophen,children's non-aspirin,fever reducer,children's fever reducing,child pain rel-fever reducer ADD UM: CUSTOM Cumulative: MED 200mg/day 03/01/2016 acetaminophen,a acetaminophen cephen,feverall ADD UM: CUSTOM Cumulative: MED 200mg/day 03/01/2016 acephen,feverall acetaminophen ADD UM: QUANTITY 13 / day 03/01/2016 acephen,feverall acetaminophen ADD UM: QUANTITY 4 / Day 03/01/2016 acephen,acetami acetaminophen nophen,feverall ADD UM: QUANTITY 6 / Day 03/01/2016 mapap,acetamin acetaminophen ophen,qpap,children's nonaspirin,children's silapap,children's pain relief,children's acetaminophen,p ain relief,edapap,children's qpap ADD UM: QUANTITY 20 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 120 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 acetaminophen,t acetaminophen actinal,pain reliever,mapap,n on-aspirin,meditabs,non-aspirin pain relief,pharbetol,p ain relief,tylenol,qpap,masophen,p ain & fever,athenol ADD UM: QUANTITY 8 / Day 03/01/2016 acetaminophen,p acetaminophen ain reliever,nonaspirin extra strength,tylenol extra strength,acetami nophen extra strength,pain relief,pain relief extra strength,shake that ache,mapap,mas ophen,tactinal,no n-aspirin pain relief,pharbetol,a cetaminophen es,q-pap extra strength,extra strength nonaspirin,meditabs,medi-tabs extra strength,pain & fever ADD UM: QUANTITY 4 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 121 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date 03/01/2016 Brand Name Generic Name acetaminophen,n acetaminophen,aspirin on-aspirin extra strength,acetami nophen extra strength,pain reliever,shake that ache,pain relief,mapap,pain relief extra strength,meditabs,genebs,aspir in free,pharbetol,ac etaminophen es,genapap,tylen ol extra strength,pain relief cool ice,non-aspirin pain relief,acetaminop hen pain relief,pain reliver super strength,tylenol extra strength arthrit,tactinal,ma sophen,maxapap ,q-pap extra strength,extra strength nonaspirin,medi-tabs extra strength,pain & fever Type of Change Previous Value ADD UM: CUSTOM New Value Cumulative: 4gm/day acetaminophen BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 122 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 children's nonacetaminophen aspirin,children's pain & fever,children's pain reliever,nonaspirin,mapap,chi ldren's tactinal,acetamin ophen,children's acetaminophen ADD UM: QUANTITY 50 / Day 03/01/2016 children's acetaminophen tactinal,children's acetaminophen,a cetaminophen,jr. acetaminophen,n onaspirin,children's pain reliever,children's nonaspirin,genapap,c hildrens acetaminophen,st . joseph fever reducer,st. joseph asa-free children's,childre n's pain & fever,mapap,child ren's pain relief ADD UM: CUSTOM Cumulative: 4gm/day acetaminophen 03/01/2016 NOVOLOG MIX insulin aspart protamine 70-30 human/insulin aspart FLEXPEN,NOVO LOG MIX 70-30 ADD UM: QUANTITY 0.667 / day 03/01/2016 glatopa,copaxone glatiramer acetate ADD UM: CUSTOM Cumulative: 4gm/day acetaminophen BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 123 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 glatopa,copaxone glatiramer acetate ADD UM: QUANTITY 1 / Day 03/01/2016 AVONEX interferon beta-1a/albumin human ADD UM: QUANTITY 0.04 / day 03/01/2016 AVONEX interferon beta-1a/albumin human ADD UM: CUSTOM Cumulative: 4gm/day acetaminophen 03/01/2016 amantadine amantadine hcl ADD UM: CUSTOM Cumulative: 4gm/day acetaminophen 03/01/2016 amantadine amantadine hcl ADD UM: QUANTITY 4 / Day 03/01/2016 NUVARING etonogestrel/ethinyl estradiol ADD UM: QUANTITY 0.034 / day 03/01/2016 NUVARING etonogestrel/ethinyl estradiol ADD UM: CUSTOM Cumulative: 4gm/day acetaminophen 03/01/2016 amantadine amantadine hcl ADD UM: CUSTOM Cumulative: 4gm/day acetaminophen 03/01/2016 amantadine amantadine hcl ADD UM: QUANTITY 20 / Day 03/01/2016 midodrine hcl,proamatine midodrine hcl ADD UM: CUSTOM Cumulative: 4gm/day acetaminophen 03/01/2016 midodrine hcl midodrine hcl ADD UM: QUANTITY 3 / Day 03/01/2016 amlodipine besylatebenazepril,lotrel amlodipine besylate/benazepril hcl ADD UM: QUANTITY 1 / Day 03/01/2016 orphenadrine citrate orphenadrine citrate ADD UM: QUANTITY 1 / Day 03/01/2016 metoprolol tartrate metoprolol tartrate ADD UM: QUANTITY 3 / Day 03/01/2016 SPIRIVA tiotropium bromide ADD UM: QUANTITY 1 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 124 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 pulmicort,budeso budesonide nide ADD UM: QUANTITY 2 / Day 03/01/2016 pulmicort,budeso budesonide nide ADD UM: QUANTITY 2 / Day 03/01/2016 celecoxib,celebre celecoxib x ADD UM: QUANTITY 1 / Day 03/01/2016 bethanechol bethanechol chloride chloride,urecholin e ADD UM: QUANTITY 2 / Day 03/01/2016 bethanechol bethanechol chloride chloride,urecholin e ADD UM: QUANTITY 2 / Day 03/01/2016 bethanechol bethanechol chloride chloride,urecholin e ADD UM: QUANTITY 2 / Day 03/01/2016 bethanechol bethanechol chloride chloride,urecholin e ADD UM: QUANTITY 2 / Day 03/01/2016 ZETIA ezetimibe ADD UM: QUANTITY 1 / Day 03/01/2016 nicotine patch nicotine ADD UM: QUANTITY 1 / Day 03/01/2016 singulair,montelu montelukast sodium kast sodium ADD UM: QUANTITY 1 / Day 03/01/2016 HUMIRA,HUMIR adalimumab A PEDIATRIC CROHN'S ADD UM: QUANTITY 0.15 / day 03/01/2016 cardizem la,matzim la,diltiazem er diltiazem hcl ADD UM: QUANTITY 1 / Day 03/01/2016 cardizem la,matzim la,diltiazem er diltiazem hcl ADD UM: QUANTITY 1 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 125 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 fentanyl,duragesi fentanyl c ADD UM: QUANTITY 0.333 / day 03/01/2016 fentanyl,duragesi fentanyl c ADD UM: QUANTITY 0.333 / day 03/01/2016 fentanyl,duragesi fentanyl c ADD UM: QUANTITY 0.333 / day 03/01/2016 fentanyl,duragesi fentanyl c ADD UM: QUANTITY 0.333 / day 03/01/2016 oxybutynin chloride oxybutynin chloride ADD UM: QUANTITY 5 / Day 03/01/2016 oxybutynin chloride oxybutynin chloride ADD UM: QUANTITY 3 / Day 03/01/2016 oxybutynin chloride er,ditropan xl oxybutynin chloride ADD UM: QUANTITY 1 / Day 03/01/2016 oxybutynin chloride er,ditropan xl oxybutynin chloride ADD UM: CUSTOM Cumulative: MED 200mg/day 03/01/2016 oxybutynin chloride er,ditropan xl oxybutynin chloride ADD UM: QUANTITY 2 / Day 03/01/2016 VIGAMOX moxifloxacin hcl ADD UM: QUANTITY 0.1 / day 03/01/2016 VIGAMOX moxifloxacin hcl ADD UM: CUSTOM Cumulative: MED 200mg/day 03/01/2016 rizatriptan,maxalt rizatriptan benzoate ADD UM: CUSTOM Cumulative: MED 200mg/day 03/01/2016 rizatriptan,maxalt rizatriptan benzoate ADD UM: QUANTITY 0.3 / day 03/01/2016 rizatriptan,maxalt rizatriptan benzoate ADD UM: QUANTITY 0.3 / day 03/01/2016 rizatriptan,maxalt rizatriptan benzoate ADD UM: CUSTOM Cumulative: MED 200mg/day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 126 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 rizatriptan,maxalt rizatriptan benzoate mlt ADD UM: QUANTITY 0.3 / day 03/01/2016 rizatriptan,maxalt rizatriptan benzoate mlt ADD UM: QUANTITY 0.3 / day 03/01/2016 PREMPRO estrogens, conjugated/medroxyprogest erone acetate ADD UM: QUANTITY 1 / Day 03/01/2016 EPIPEN JR 2PAK epinephrine ADD UM: QUANTITY 0.02 / day 03/01/2016 auviepinephrine q,epinephrine,adr enaclick,epipen 2-pak ADD UM: QUANTITY 0.02 / day 03/01/2016 pramipexole pramipexole di-hcl dihydrochloride,m irapex ADD UM: QUANTITY 1 / Day 03/01/2016 mirapex,pramipe pramipexole di-hcl xole dihydrochloride ADD UM: CUSTOM Cumulative: 9/30 day across oral triptans 03/01/2016 pramipexole pramipexole di-hcl dihydrochloride,m irapex ADD UM: QUANTITY 1 / Day 03/01/2016 pramipexole pramipexole di-hcl dihydrochloride,m irapex ADD UM: CUSTOM Cumulative: 9/30 day across oral triptans 03/01/2016 pramipexole pramipexole di-hcl dihydrochloride,m irapex ADD UM: QUANTITY 1 / Day 03/01/2016 pramipexole pramipexole di-hcl dihydrochloride,m irapex ADD UM: CUSTOM Cumulative: 9/30 day across oral triptans BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 127 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 mirapex,pramipe pramipexole di-hcl xole dihydrochloride ADD UM: QUANTITY 1 / Day 03/01/2016 mirapex,pramipe pramipexole di-hcl xole dihydrochloride ADD UM: CUSTOM Cumulative: 9/30 day across oral triptans 03/01/2016 pramipexole pramipexole di-hcl dihydrochloride,m irapex ADD UM: QUANTITY 1 / Day 03/01/2016 PREMARIN estrogens, conjugated ADD UM: QUANTITY 1 / Day 03/01/2016 ondansetron hcl,zofran ondansetron hcl ADD UM: QUANTITY 5 / Day 03/01/2016 ondansetron hcl,zofran ondansetron hcl ADD UM: QUANTITY 0.6 / day 03/01/2016 ondansetron hcl,zofran ondansetron hcl ADD UM: QUANTITY 0.8 / day 03/01/2016 ondansetron odt,zofran odt ondansetron ADD UM: QUANTITY 0.6 / day 03/01/2016 ondansetron odt,zofran odt ondansetron ADD UM: QUANTITY 0.8 / day 03/01/2016 estradiol,climara estradiol ADD UM: QUANTITY 0.133 / day 03/01/2016 estradiol,climara estradiol ADD UM: QUANTITY 0.133 / day 03/01/2016 AVONEX interferon beta-1a ADD UM: QUANTITY 0.143 / day 03/01/2016 myorisan,absoric isotretinoin a,zenatane,sotret ,claravis ADD UM: QUANTITY 1 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 128 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 pseudoephedrine pseudoephedrine hcl hcl,suphedrine,na sal decongestant,nas al & sinus decongestant,sup hedrine sinus congestion,suphe drin,walphed,sudogest,m edi-phedrine ADD UM: QUANTITY 1 / Day 03/01/2016 pseudoephedrine pseudoephedrine hcl hcl,sudogest ADD UM: QUANTITY 1 / Day 03/01/2016 metoprolol metoprolol tartrate tartrate,lopressor ADD UM: QUANTITY 3 / Day 03/01/2016 metoprolol metoprolol tartrate tartrate,lopressor ADD UM: QUANTITY 3 / Day 03/01/2016 metoprolol succinate,toprol xl metoprolol succinate ADD UM: QUANTITY 1.5 / day 03/01/2016 metoprolol succinate,toprol xl metoprolol succinate ADD UM: QUANTITY 1.5 / day 03/01/2016 metoprolol succinate,toprol xl metoprolol succinate ADD UM: QUANTITY 2 / Day 03/01/2016 PREMPRO estrogens, conjugated/medroxyprogest erone acetate ADD UM: QUANTITY 1 / Day 03/01/2016 namenda,meman memantine hcl tine hcl ADD UM: QUANTITY 2 / Day 03/01/2016 AFINITOR everolimus ADD UM: QUANTITY 1 / Day 03/01/2016 AFINITOR everolimus ADD UM: QUANTITY 2 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 129 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 AVONEX interferon beta-1a ADD UM: QUANTITY 0.143 / day 03/01/2016 lacammonium lactate hydrin,ammoniu m lactate,al12,gerihydrolac,amlactin ,laclotion,lachydrin twelve,moist skin,skin treatment ADD UM: QUANTITY 7.5 / day 03/01/2016 torsemide,demad torsemide ex ADD UM: QUANTITY 2 / Day 03/01/2016 demadex,torsemi torsemide de ADD UM: QUANTITY 4 / Day 03/01/2016 torsemide,demad torsemide ex ADD UM: QUANTITY 4 / Day 03/01/2016 torsemide,demad torsemide ex ADD UM: QUANTITY 2 / Day 03/01/2016 SENSIPAR cinacalcet hcl ADD UM: QUANTITY 2 / Day 03/01/2016 SENSIPAR cinacalcet hcl ADD UM: QUANTITY 2 / Day 03/01/2016 SENSIPAR cinacalcet hcl ADD UM: QUANTITY 4 / Day 03/01/2016 ASACOL HD mesalamine ADD UM: QUANTITY 6 / Day 03/01/2016 alendronate sodium alendronate sodium ADD UM: QUANTITY 0.133 / day 03/01/2016 alendronate sodium alendronate sodium ADD UM: QUANTITY 0.133 / day 03/01/2016 alendronate sodium alendronate sodium ADD UM: QUANTITY 0.133 / day 03/01/2016 vinate ii prenatal vitamins with calcium/fe bisgly/folic acid ADD UM: QUANTITY 1 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 130 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 children's walcetirizine hcl zyr,cetirizine hcl,zyrtec,all day allergy,children's cetirizine hcl,children's allergy relief ADD UM: QUANTITY 1 / Day 03/01/2016 children's allergy cetirizine hcl relief,cetirizine hcl,children's cetirizine hcl,all day allergy,allergy relief,children's walzyr,zyrtec,childre n's zyrtec ADD UM: QUANTITY 1 / Day 03/01/2016 omeprazole omeprazole ADD UM: QUANTITY 2 / Day 03/01/2016 retin-a,tretinoin tretinoin ADD UM: QUANTITY 1.5 / day 03/01/2016 retina,tretinoin,avita tretinoin ADD UM: QUANTITY 1.5 / day 03/01/2016 tretinoin,retin-a tretinoin ADD UM: QUANTITY 1.5 / day 03/01/2016 tretinoin,retin-a tretinoin ADD UM: QUANTITY 1.5 / day 03/01/2016 tretinoin,retina,avita tretinoin ADD UM: QUANTITY 1.5 / day 03/01/2016 PROAIR albuterol sulfate HFA,VENTOLIN HFA,PROVENTI L HFA ADD UM: QUANTITY 0.6 / day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 131 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 persa-gel,benzoyl benzoyl peroxide peroxide,panoxyl, desquamx,benzac ac,acneclear,acn e treatment,acne 10,acne medication,benza c w wash,acne pimple medication,bp ADD UM: QUANTITY 2 / Day 03/01/2016 lacammonium lactate hydrin,ammoniu m lactate,lactrex,am lactin,gerihydrolac ADD UM: QUANTITY 4.667 / day 03/01/2016 periogard,chlorhe chlorhexidine gluconate xidine gluconate,paroex ,peridex ADD UM: QUANTITY 1 / Day 03/01/2016 calcitonincalcitonin,salmon,synthetic salmon,fortical,mi acalcin ADD UM: QUANTITY 0.107 / day 03/01/2016 carbidopacarbidopa/levodopa levodopa,parcop a ADD UM: QUANTITY 1 / Day 03/01/2016 PENTASA mesalamine ADD UM: QUANTITY 8 / Day 03/01/2016 ENBREL etanercept ADD UM: QUANTITY 0.14 / day 03/01/2016 clonidine,catapre clonidine s-tts 3 ADD UM: QUANTITY 0.143 / day 03/01/2016 OBSTETRIX EC prenatal vitamin w-o calcium/iron,carbonyl/docus ate/fa ADD UM: QUANTITY 1 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 132 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name 03/01/2016 ibandronate sodium,boniva 03/01/2016 Generic Name ibandronate sodium Type of Change Previous Value New Value ADD UM: QUANTITY 0.036 / day HUMULIN 70/30 insulin nph human KWIKPEN,HUMU isophane/insulin regular, LIN 70-30 human ADD UM: QUANTITY 0.667 / day 03/01/2016 ATROVENT HFA ipratropium bromide ADD UM: QUANTITY 0.43 / day 03/01/2016 fentanyl,duragesi fentanyl c ADD UM: QUANTITY 0.333 / day 03/01/2016 imitrex,sumatripta sumatriptan succinate n succinate ADD UM: QUANTITY 1 / month 03/01/2016 tri-vita,tripediatric multivitamin vitamin,trivitamin a,c,and d3 no.21,pediatric multivitamins a,c,& d3 no.21 ADD UM: QUANTITY 2 / Day 03/01/2016 GLUCAGON EMERGENCY KIT glucagon,human recombinant ADD UM: QUANTITY 0.034 / day 03/01/2016 gemfibrozil,lopid gemfibrozil ADD UM: QUANTITY 2 / Day 03/01/2016 nutrinate,natache prenatal vitamins combo w,completenate,p no.14/ferrous fumarate/folic renatal acid multivitamin wiron ADD UM: QUANTITY 1 / Day 03/01/2016 M-VIT ADD UM: QUANTITY 1 / Day 03/01/2016 losartanlosartan hydrochlorothiazi potassium/hydrochlorothiazi de,hyzaar de ADD UM: QUANTITY 1 / Day 03/01/2016 hyzaar,losartan- losartan hydrochlorothiazi potassium/hydrochlorothiazi de de ADD UM: CUSTOM Cumulative: MED 200mg/day prenatal vitamin w-o calcium/ferrous fumarate/folic acid BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 133 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 gavilytesodium chloride/sodium n,nulytely with bicarbonate/potassium flavor packs,peg chloride/peg 3350electrolyte,trilyte with flavor packets,peg3350 with flavor packs ADD UM: QUANTITY 10.959 / day 03/01/2016 gavilyte-n,peg sodium chloride/sodium 3350bicarbonate/potassium electrolyte,peg- chloride/peg 3350 with flavor packs,trilyte with flavor packets,nulytely with flavor packs,nulytely ADD UM: CUSTOM Cumulative: 2 syringes/30 days across inj triptans 03/01/2016 APIDRA ADD UM: QUANTITY 2 / Day 03/01/2016 bromocriptine bromocriptine mesylate mesylate,parlodel ADD UM: QUANTITY 6 / Day 03/01/2016 desmopressin acetate,ddavp desmopressin acetate ADD UM: QUANTITY 1 / Day 03/01/2016 desmopressin acetate,ddavp desmopressin acetate ADD UM: QUANTITY 1 / Day 03/01/2016 VICTOZA 3liraglutide PAK,VICTOZA 2PAK ADD UM: QUANTITY 0.134 / day 03/01/2016 repaglinide,prand repaglinide in ADD UM: QUANTITY 4 / Day 03/01/2016 prandin,repaglini repaglinide de ADD UM: QUANTITY 4 / Day 03/01/2016 repaglinide,prand repaglinide in ADD UM: QUANTITY 4 / Day insulin glulisine BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 134 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 REVLIMID lenalidomide ADD UM: QUANTITY 1 / Day 03/01/2016 REVLIMID lenalidomide ADD UM: QUANTITY 1 / Day 03/01/2016 infant's pain acetaminophen relief,infant's nonaspirin,mapap infant,infant's pain reliever,acetamin ophen,infants' pain reliever ADD UM: QUANTITY 40 / Day 03/01/2016 simvastatin,zocor simvastatin ADD UM: QUANTITY 1 / Day 03/01/2016 simvastatin,zocor simvastatin ADD UM: QUANTITY 1 / Day 03/01/2016 simvastatin,zocor simvastatin ADD UM: QUANTITY 1 / Day 03/01/2016 simvastatin,zocor simvastatin ADD UM: QUANTITY 1 / Day 03/01/2016 simvastatin,zocor simvastatin ADD UM: QUANTITY 1 / Day 03/01/2016 ADCIRCA ADD UM: QUANTITY 2 / Day 03/01/2016 imitrex,sumatripta sumatriptan succinate n succinate ADD UM: CUSTOM Cumulative: 4gm/day acetaminophen 03/01/2016 imitrex,sumatripta sumatriptan succinate n succinate ADD UM: QUANTITY 1 / month 03/01/2016 imitrex,sumatripta sumatriptan succinate n succinate ADD UM: QUANTITY 1 / month 03/01/2016 linezolid,zyvox ADD UM: QUANTITY 900 / rx tadalafil linezolid BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 135 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 children's nonacetaminophen aspirin,children's pain relief,children's pain-fever,infants' pain-fever,fever reducer-pain reliever,children's pain reliever,children's acetaminophen,in fants' pain reliever,infants' pain relief,infant pain-fever,infant pain relief,infant's pain relief,little remedies feverpain,children's tylenol,acetamino phen,children's qpap,infants' tylenol,infant fever-pain reliever,nonaspirin,mapap,inf ants' mapap,children's meditabs,pediacare fever reducer,nortemp, betatemp ADD UM: QUANTITY 20 / Day 03/01/2016 amlodipine besylatebenazepril,lotrel ADD UM: QUANTITY 1 / Day amlodipine besylate/benazepril hcl BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 136 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 amlodipine besylatebenazepril,lotrel amlodipine besylate/benazepril hcl ADD UM: QUANTITY 1 / Day 03/01/2016 CHANTIX varenicline tartrate ADD UM: QUANTITY 2 / Day 03/01/2016 CHANTIX varenicline tartrate CHANGE UM: CUSTOM Max. 24 weeks Cumulative: 2 therapy per year syringes/30 days across inj triptans 03/01/2016 CHANTIX varenicline tartrate CHANGE UM: CUSTOM Max. 24 weeks Cumulative: 2 therapy per year syringes/30 days across inj triptans 03/01/2016 CHANTIX varenicline tartrate ADD UM: QUANTITY 2 / Day 03/01/2016 CHANTIX varenicline tartrate ADD UM: QUANTITY 2 / Day 03/01/2016 prenatal-u,pnvvp-u,triveen-u prenatal vits without calc no5/ferrous fumarate/folic acid ADD UM: QUANTITY 1 / Day 03/01/2016 prenatal-u,pnvvp-u,triveen-u prenatal vits without calc no5/ferrous fumarate/folic acid ADD UM: CUSTOM Cumulative: 4gm/day acetaminophen 03/01/2016 REVLIMID lenalidomide ADD UM: CUSTOM Cumulative: 4gm/day acetaminophen 03/01/2016 REVLIMID lenalidomide ADD UM: QUANTITY 1 / Day 03/01/2016 REVLIMID lenalidomide ADD UM: QUANTITY 1 / Day 03/01/2016 quinapril hcl,accupril quinapril hcl ADD UM: QUANTITY 1 / Day 03/01/2016 quinapril hcl,accupril quinapril hcl ADD UM: CUSTOM Max 2-12 wk courses of therapy per yr 03/01/2016 accupril,quinapril quinapril hcl hcl ADD UM: QUANTITY 1 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 137 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 quinapril hcl,accupril quinapril hcl ADD UM: CUSTOM Max 2-12 wk courses of therapy per yr 03/01/2016 quinapril hcl,accupril quinapril hcl ADD UM: QUANTITY 1 / Day 03/01/2016 quinapril hcl,accupril quinapril hcl ADD UM: QUANTITY 1 / Day 03/01/2016 quinapril hcl,accupril quinapril hcl ADD UM: CUSTOM Max 2-12 wk courses of therapy per yr 03/01/2016 spironolactone,al spironolactone dactone ADD UM: QUANTITY 1 / Day 03/01/2016 spironolactone,al spironolactone dactone ADD UM: QUANTITY 1 / Day 03/01/2016 spironolactone,al spironolactone dactone ADD UM: QUANTITY 1 / Day 03/01/2016 amiloride hcl amiloride hcl ADD UM: QUANTITY 1 / Day 03/01/2016 cetirizine hcl cetirizine hcl ADD UM: QUANTITY 1 / Day 03/01/2016 bupropion hcl bupropion hcl sr,zyban,buproba n ADD UM: QUANTITY 2 / Day 03/01/2016 epinephrine,auvi- epinephrine q,adrenaclick ADD UM: QUANTITY 0.02 / day 03/01/2016 midodrine hcl midodrine hcl ADD UM: QUANTITY 3 / Day 03/01/2016 midodrine hcl midodrine hcl ADD UM: QUANTITY 3 / Day 03/01/2016 PREMARIN estrogens, conjugated ADD UM: QUANTITY 1.5 / day 03/01/2016 omeprazole magnesium omeprazole magnesium ADD UM: QUANTITY 1 / Day 03/01/2016 budesonide ec,entocort ec budesonide ADD UM: QUANTITY 3 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 138 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 prenatal prenatal vits with calcium plus,preplus,pren #72/ferrous fumarate/folic atal vitamin plus acid low iron ADD UM: QUANTITY 1 / Day 03/01/2016 prenatal low prenatal vits with calcium iron,vol#74/ferrous fumarate/folic plus,prenaplus,ni acid va-plus ADD UM: QUANTITY 1 / Day 03/01/2016 DULERA mometasone furoate/formoterol fumarate ADD UM: QUANTITY 0.034 / day 03/01/2016 DULERA mometasone furoate/formoterol fumarate ADD UM: QUANTITY 0.034 / day 03/01/2016 AFINITOR everolimus ADD UM: QUANTITY 1 / Day 03/01/2016 re-nata 29 prenatal vits with calcium ob,prenatabs #76/iron,carbonyl/folic acid rx,pnv 291,thrivite rx,natalv rx,vol-tab rx ADD UM: QUANTITY 1 / Day 03/01/2016 alora,estradiol,mi estradiol nivelle,vivelle-dot ADD UM: QUANTITY 0.0308 / day 03/01/2016 alora,vivelleestradiol dot,minivelle,estr adiol ADD UM: QUANTITY 0.286 / day 03/01/2016 minivelle,estradio estradiol l,vivelle-dot,alora ADD UM: QUANTITY 0.267 / day 03/01/2016 alora,estradiol,mi estradiol nivelle,vivelle-dot ADD UM: QUANTITY 0.0308 / day 03/01/2016 estradiol,climara estradiol ADD UM: QUANTITY 0.154 / day 03/01/2016 climara,estradiol estradiol ADD UM: QUANTITY 0.154 / day 03/01/2016 minivelle,estradio estradiol l,vivelle-dot ADD UM: QUANTITY 0.267 / day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 139 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 climara,estradiol estradiol ADD UM: QUANTITY 0.154 / day 03/01/2016 climara,estradiol estradiol ADD UM: QUANTITY 0.154 / day 03/01/2016 tri-vitamin with fluoride,triplevitamin wfluoride,trivitaminfluoride,vitamins a,c,d & fluoride,vitamins a,d,c & fluoride pediatric multivitamins a,c,& d3 no.21 with sodium fluoride,fluoride/vitamins a,c,and d ADD UM: QUANTITY 2 / Day 03/01/2016 vp-heme prenatal vit no.21/iron ob,prefera polysacch,heme ob,hemenatal ob polypep/folic acid ADD UM: QUANTITY 1 / Day 03/01/2016 differin,adapalen adapalene e ADD UM: QUANTITY 1.5 / day 03/01/2016 adapalene,differi adapalene n ADD UM: QUANTITY 1.5 / day 03/01/2016 nestabs,vnatal,nutri-tab ob,newgen prenatal vitamin no.86/iron bis-glycinate/folic acid ADD UM: QUANTITY 1 / Day 03/01/2016 ZYTIGA abiraterone acetate ADD UM: QUANTITY 4 / Day 03/01/2016 THERANATAL prenatal vitamins combo no.28/ferrous fumarate/folic acid ADD UM: QUANTITY 1 / Day 03/01/2016 PENTASA mesalamine ADD UM: QUANTITY 8 / Day 03/01/2016 AVONEX PEN interferon beta-1a ADD UM: QUANTITY 0.143 / day 03/01/2016 spectazole,econa econazole nitrate zole nitrate ADD UM: QUANTITY 1 / Day 03/01/2016 finasteride,prosca finasteride r ADD UM: QUANTITY 1 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 140 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 lidocaine lidocaine ADD UM: QUANTITY 1 / Day 03/01/2016 XARELTO rivaroxaban ADD UM: QUANTITY 1 / Day 03/01/2016 XARELTO rivaroxaban ADD UM: QUANTITY 1 / Day 03/01/2016 westcort,hydrocor hydrocortisone valerate tisone valerate ADD UM: QUANTITY 4 / Day 03/01/2016 JAKAFI ruxolitinib phosphate ADD UM: QUANTITY 2 / Day 03/01/2016 JAKAFI ruxolitinib phosphate ADD UM: QUANTITY 2 / Day 03/01/2016 JAKAFI ruxolitinib phosphate ADD UM: QUANTITY 2 / Day 03/01/2016 JAKAFI ruxolitinib phosphate ADD UM: QUANTITY 2 / Day 03/01/2016 JAKAFI ruxolitinib phosphate ADD UM: QUANTITY 2 / Day 03/01/2016 prenatal prenatal vits with calcium multivitamins,pre #95/ferrous fumarate/folic natal,prenatal acid vitamins,prenatal formula ADD UM: QUANTITY 1 / Day 03/01/2016 tri-vitamin with fluoride,trivitamins with fluoride pediatric multivitamins a,c,& d3 no.21 with sodium fluoride,fluoride/vitamins a,c,and d ADD UM: QUANTITY 2 / Day 03/01/2016 betamethasone betamethasone dipropionate dipropionate,dipr osone ADD UM: QUANTITY 1.5 / day 03/01/2016 betamethasone betamethasone valerate valerate,beta-val ADD UM: QUANTITY 1.5 / day 03/01/2016 betamethasone valerate betamethasone valerate ADD UM: QUANTITY 1.5 / day 03/01/2016 betamethasone betamethasone valerate valerate,beta-val ADD UM: QUANTITY 2 / Day 03/01/2016 triamcinolone acetonide ADD UM: QUANTITY 5.333 / day triamcinolone acetonide BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 141 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 triamcinolone triamcinolone acetonide acetonide,triderm ADD UM: QUANTITY 5.333 / day 03/01/2016 triamcinolone acetonide triamcinolone acetonide ADD UM: QUANTITY 2 / Day 03/01/2016 triamcinolone acetonide triamcinolone acetonide ADD UM: QUANTITY 5.333 / day 03/01/2016 triamcinolone acetonide triamcinolone acetonide ADD UM: QUANTITY 5.333 / day 03/01/2016 triamcinolone acetonide triamcinolone acetonide ADD UM: QUANTITY 4 / Day 03/01/2016 nizoral,ketoconaz ketoconazole ole ADD UM: QUANTITY 4 / Day 03/01/2016 ERIVEDGE vismodegib ADD UM: QUANTITY 1 / Day 03/01/2016 JANUMET XR sitagliptin phosphate/metformin hcl ADD UM: QUANTITY 1 / Day 03/01/2016 JANUMET XR sitagliptin phosphate/metformin hcl ADD UM: QUANTITY 1 / Day 03/01/2016 JANUMET XR sitagliptin phosphate/metformin hcl ADD UM: QUANTITY 1 / Day 03/01/2016 fluocinonide,lidex fluocinonide ADD UM: QUANTITY 1 / Day 03/01/2016 fluocinonide fluocinonide ADD UM: QUANTITY 1 / Day 03/01/2016 fluocinonide fluocinonide ADD UM: QUANTITY 2 / Day 03/01/2016 ovide,malathion malathion ADD UM: QUANTITY 1.97 / day 03/01/2016 meloxicam,mobic meloxicam ADD UM: QUANTITY 1 / Day 03/01/2016 mobic,meloxicam meloxicam ADD UM: QUANTITY 1 / Day 03/01/2016 ketoconazole,niz ketoconazole oral,kuric ADD UM: QUANTITY 2 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 142 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 triamcinolone triamcinolone acetonide acetonide,oralon e,kenalog in orabase ADD UM: QUANTITY 0.167 / day 03/01/2016 clobetasol clobetasol propionate propionate,temov ate,cormax ADD UM: QUANTITY 1 / Day 03/01/2016 temovate,clobeta clobetasol propionate sol propionate,corma x,embeline ADD UM: QUANTITY 1 / Day 03/01/2016 trandolapril,mavik trandolapril ADD UM: QUANTITY 1 / Day 03/01/2016 trandolapril,mavik trandolapril ADD UM: QUANTITY 1 / Day 03/01/2016 trandolapril,mavik trandolapril ADD UM: QUANTITY 1 / Day 03/01/2016 COMBIVENT RESPIMAT ipratropium bromide/albuterol sulfate ADD UM: QUANTITY 0.267 / day 03/01/2016 verapamil er,calan sr verapamil hcl ADD UM: QUANTITY 1 / Day 03/01/2016 verapamil er,calan sr verapamil hcl ADD UM: QUANTITY 1 / Day 03/01/2016 verapamil er,calan sr verapamil hcl ADD UM: QUANTITY 1 / Day 03/01/2016 guanfacine hcl,tenex guanfacine hcl ADD UM: QUANTITY 2 / Day 03/01/2016 guanfacine hcl,tenex guanfacine hcl ADD UM: QUANTITY 2 / Day 03/01/2016 prenatal multi + dha prenatal vitamin no.51/iron fumarate/fa/omega3/dha/epa ADD UM: QUANTITY 1 / Day 03/01/2016 latanoprost,xalata latanoprost n ADD UM: QUANTITY 0.083 / day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 143 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 nabumetone nabumetone ADD UM: QUANTITY 2 / Day 03/01/2016 nabumetone nabumetone ADD UM: QUANTITY 2 / Day 03/01/2016 TUDORZA PRESSAIR aclidinium bromide ADD UM: QUANTITY 0.4 / day 03/01/2016 amlodipine besylatebenazepril,lotrel amlodipine besylate/benazepril hcl ADD UM: QUANTITY 1 / Day 03/01/2016 amlodipine besylatebenazepril,lotrel amlodipine besylate/benazepril hcl ADD UM: QUANTITY 1 / Day 03/01/2016 amlodipine besylatebenazepril,lotrel amlodipine besylate/benazepril hcl ADD UM: QUANTITY 1 / Day 03/01/2016 XTANDI enzalutamide ADD UM: QUANTITY 4 / Day 03/01/2016 fluorometholone,f fluorometholone ml ADD UM: QUANTITY 5 / Day 03/01/2016 FML FORTE fluorometholone ADD UM: QUANTITY 0.333 / day 03/01/2016 dorzolamide hcl,trusopt dorzolamide hcl ADD UM: QUANTITY 0.333 / day 03/01/2016 doxazosin doxazosin mesylate mesylate,cardura ADD UM: QUANTITY 1 / Day 03/01/2016 doxazosin doxazosin mesylate mesylate,cardura ADD UM: QUANTITY 1 / Day 03/01/2016 doxazosin doxazosin mesylate mesylate,cardura ADD UM: QUANTITY 1 / Day 03/01/2016 doxazosin doxazosin mesylate mesylate,cardura ADD UM: QUANTITY 2 / Day 03/01/2016 ciprofloxacin hcl,ciloxan ADD UM: QUANTITY 0.167 / day ciprofloxacin hcl BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 144 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name 03/01/2016 prenatal plus 03/01/2016 Generic Name prenatal vits with calcium #72/iron,carbonyl/folic acid Type of Change Previous Value New Value ADD UM: QUANTITY 1 / Day nateglinide,starlix nateglinide ADD UM: QUANTITY 3 / Day 03/01/2016 ropinirole hcl,requip ropinirole hcl ADD UM: QUANTITY 1 / Day 03/01/2016 ropinirole hcl,requip ropinirole hcl ADD UM: QUANTITY 1 / Day 03/01/2016 ropinirole hcl,requip ropinirole hcl ADD UM: QUANTITY 1 / Day 03/01/2016 ropinirole hcl,requip ropinirole hcl ADD UM: QUANTITY 1 / Day 03/01/2016 ropinirole hcl,requip ropinirole hcl ADD UM: QUANTITY 1 / Day 03/01/2016 flunisolide flunisolide ADD UM: QUANTITY 0.833 / day 03/01/2016 FARXIGA dapagliflozin propanediol ADD UM: QUANTITY 1 / Day 03/01/2016 TECFIDERA dimethyl fumarate ADD UM: QUANTITY 0.164 / day 03/01/2016 TECFIDERA dimethyl fumarate ADD UM: QUANTITY 2 / Day 03/01/2016 TECFIDERA dimethyl fumarate ADD UM: QUANTITY 2 / Day 03/01/2016 INVOKANA canagliflozin ADD UM: QUANTITY 1 / Day 03/01/2016 INVOKANA canagliflozin ADD UM: QUANTITY 1 / Day 03/01/2016 AFINITOR DISPERZ everolimus ADD UM: QUANTITY 2 / Day 03/01/2016 AFINITOR DISPERZ everolimus ADD UM: QUANTITY 2 / Day 03/01/2016 AFINITOR DISPERZ everolimus ADD UM: CUSTOM Max 1 Starter Pack per year 03/01/2016 AFINITOR DISPERZ everolimus ADD UM: QUANTITY 2 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 145 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 hydrochlorothiazi hydrochlorothiazide de,microzide ADD UM: QUANTITY 1 / Day 03/01/2016 hydrochlorothiazi hydrochlorothiazide de ADD UM: QUANTITY 1 / Day 03/01/2016 hydrochlorothiazi hydrochlorothiazide de ADD UM: QUANTITY 1 / Day 03/01/2016 furosemide,lasix furosemide ADD UM: QUANTITY 1 / Day 03/01/2016 furosemide,lasix furosemide ADD UM: QUANTITY 1 / Day 03/01/2016 lasix,furosemide furosemide ADD UM: QUANTITY 1 / Day 03/01/2016 chlorthalidone chlorthalidone ADD UM: QUANTITY 4 / Day 03/01/2016 chlorthalidone chlorthalidone ADD UM: QUANTITY 4 / Day 03/01/2016 metolazone metolazone ADD UM: QUANTITY 1 / Day 03/01/2016 zaroxolyn,metola metolazone zone ADD UM: QUANTITY 1 / Day 03/01/2016 metolazone,zarox metolazone olyn ADD UM: QUANTITY 1 / Day 03/01/2016 ADEMPAS riociguat ADD UM: QUANTITY 3 / Day 03/01/2016 ADEMPAS riociguat ADD UM: QUANTITY 3 / Day 03/01/2016 ADEMPAS riociguat ADD UM: QUANTITY 3 / Day 03/01/2016 ADEMPAS riociguat ADD UM: QUANTITY 3 / Day 03/01/2016 ADEMPAS riociguat ADD UM: QUANTITY 3 / Day 03/01/2016 ibuprofen,walibuprofen profen,advil liquigels,advil migraine,advil ADD UM: QUANTITY 1 / Day 03/01/2016 ibuprofen,walibuprofen profen,advil liquigels,advil migraine,advil ADD UM: QUANTITY 2 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 146 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 colcrys,colchicine colchicine ADD UM: QUANTITY 4 / Day 03/01/2016 FARXIGA dapagliflozin propanediol ADD UM: QUANTITY 1 / Day 03/01/2016 AEROSPAN flunisolide ADD UM: QUANTITY 0.6 / day 03/01/2016 children's ibuprofen ibuprofen,ibuprof en,child ibuprofen,childre n's motrin,children's profenib,children' s mediprofen,children's advil,children's profen ib ADD UM: QUANTITY 10 / day 03/01/2016 children's ibuprofen ibuprofen,ibuprof en,child ibuprofen,childre n's motrin,children's profenib,children' s mediprofen,children's advil,children's profen ib ADD UM: QUANTITY 1 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 147 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 infants ibuprofen ibuprofen,infant's ibuprofen,infants ibu-drops,infants' ibuprofen,infant's motrin,infants' motrin,ibuprofen,i budrops,children's ibuprofen,infants mediprofen,infants profenib ADD UM: QUANTITY 80 / day 03/01/2016 infants ibuprofen ibuprofen,infant's ibuprofen,infants ibu-drops,infants' ibuprofen,infant's motrin,infants' motrin,ibuprofen,i budrops,children's ibuprofen,infants mediprofen,infants profenib ADD UM: QUANTITY 3 / Day 03/01/2016 children's triamcinolone acetonide nasacort,nasacor t,nasal allergy ADD UM: QUANTITY 0.563 / day 03/01/2016 FORADIL formoterol fumarate ADD UM: QUANTITY 2 / Day 03/01/2016 INVOKAMET canagliflozin/metformin hcl ADD UM: QUANTITY 1 / Day 03/01/2016 INVOKAMET canagliflozin/metformin hcl ADD UM: QUANTITY 1 / Day 03/01/2016 INVOKAMET canagliflozin/metformin hcl ADD UM: QUANTITY 1 / Day 03/01/2016 detrol,tolterodine tolterodine tartrate tartrate ADD UM: QUANTITY 2 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 148 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 tolterodine tartrate,detrol tolterodine tartrate ADD UM: QUANTITY 2 / Day 03/01/2016 HUMIRA adalimumab ADD UM: QUANTITY 0.08 / day 03/01/2016 tamoxifen citrate tamoxifen citrate ADD UM: QUANTITY 2 / Day 03/01/2016 tamoxifen citrate tamoxifen citrate ADD UM: QUANTITY 2 / Day 03/01/2016 sotalol,sotalol sotalol hcl af,sorine,betapac e af,betapace ADD UM: QUANTITY 2 / Day 03/01/2016 sotalol,sotalol sotalol hcl af,betapace af,sorine,betapac e ADD UM: QUANTITY 2 / Day 03/01/2016 sorine,sotalol,bet sotalol hcl apace ADD UM: QUANTITY 2 / Day 03/01/2016 sotalol,sotalol sotalol hcl af,sorine,betapac e,betapace af ADD UM: QUANTITY 2 / Day 03/01/2016 protonix,pantopra pantoprazole sodium zole sodium ADD UM: QUANTITY 1 / Day 03/01/2016 ELMIRON ADD UM: QUANTITY 3 / Day 03/01/2016 nitrofurantoin,ma nitrofurantoin macrocrystal crodantin ADD UM: QUANTITY 2 / Day 03/01/2016 nitrofurantoin,ma nitrofurantoin macrocrystal crodantin ADD UM: QUANTITY 2 / Day 03/01/2016 celebrex,celecoxi celecoxib b ADD UM: QUANTITY 1 / Day 03/01/2016 celecoxib,celebre celecoxib x ADD UM: QUANTITY 1 / Day 03/01/2016 zolmitriptan odt,zomig zmt ADD UM: QUANTITY 0.3 / day pentosan polysulfate sodium zolmitriptan BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 149 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 atrovent,ipratropi ipratropium bromide um bromide ADD UM: QUANTITY 1 / Day 03/01/2016 atrovent,ipratropi ipratropium bromide um bromide ADD UM: QUANTITY 1 / Day 03/01/2016 montelukast sodium,singulair montelukast sodium ADD UM: QUANTITY 1 / Day 03/01/2016 nystatin nystatin ADD UM: QUANTITY 1 / Day 03/01/2016 ketoconazole ketoconazole ADD UM: QUANTITY 2 / Day 03/01/2016 chloroquine phosphate chloroquine phosphate ADD UM: QUANTITY 1 / Day 03/01/2016 chloroquine chloroquine phosphate phosphate,aralen phosphate ADD UM: CUSTOM Cumulative: 9/30 day across oral triptans 03/01/2016 chloroquine phosphate chloroquine phosphate ADD UM: QUANTITY 1 / Day 03/01/2016 atorvastatin calcium,lipitor atorvastatin calcium ADD UM: QUANTITY 1 / Day 03/01/2016 lipitor,atorvastatin atorvastatin calcium calcium ADD UM: QUANTITY 1 / Day 03/01/2016 atorvastatin calcium,lipitor atorvastatin calcium ADD UM: QUANTITY 1 / Day 03/01/2016 atorvastatin calcium,lipitor atorvastatin calcium ADD UM: QUANTITY 1 / Day 03/01/2016 acyclovir,zovirax acyclovir ADD UM: QUANTITY 2 / Day 03/01/2016 permethrin,acticin permethrin ,elimite ADD UM: QUANTITY 2 / Day 03/01/2016 lice permethrin treatment,nix,per methrin,lice killing,lice cream rinse ADD UM: QUANTITY 1.97 / day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 150 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 bisoprololbisoprolol hydrochlorothiazi fumarate/hydrochlorothiazid de,ziac e ADD UM: QUANTITY 1.5 / day 03/01/2016 ziac,bisoprololbisoprolol hydrochlorothiazi fumarate/hydrochlorothiazid de e ADD UM: QUANTITY 1.5 / day 03/01/2016 bisoprololbisoprolol hydrochlorothiazi fumarate/hydrochlorothiazid de,ziac e ADD UM: QUANTITY 2 / Day 03/01/2016 elocon,mometaso mometasone furoate ne furoate ADD UM: QUANTITY 1.5 / day 03/01/2016 zolmitriptan,zomi zolmitriptan g ADD UM: QUANTITY 0.3 / day 03/01/2016 zolmitriptan,zomi zolmitriptan g ADD UM: QUANTITY 0.3 / day 03/01/2016 allergy clemastine fumarate relief,clemastine fumarate,dailyhist -1,allerhist1,dayhist allergy,tavist1,dayhist ADD UM: QUANTITY 1 / Day 03/01/2016 azathioprine,imur azathioprine an ADD UM: QUANTITY 8 / Day 03/01/2016 mevacor,lovastati lovastatin n ADD UM: QUANTITY 1 / Day 03/01/2016 lovastatin,mevac lovastatin or ADD UM: QUANTITY 1 / Day 03/01/2016 lovastatin lovastatin ADD UM: QUANTITY 1 / Day 03/01/2016 terazosin hcl terazosin hcl ADD UM: CUSTOM Cumulative: 9/30 day across oral triptans BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 151 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 terazosin hcl terazosin hcl ADD UM: QUANTITY 1 / Day 03/01/2016 terazosin hcl terazosin hcl ADD UM: QUANTITY 2 / Day 03/01/2016 terazosin hcl,hytrin terazosin hcl ADD UM: CUSTOM Cumulative: 9/30 day across oral triptans 03/01/2016 terazosin hcl terazosin hcl ADD UM: QUANTITY 1 / Day 03/01/2016 terazosin hcl terazosin hcl ADD UM: QUANTITY 2 / Day 03/01/2016 naproxen naproxen sodium sodium,flanax,all day relief,all day pain relief,mediproxen ,walproxen,aleve,mid ol ADD UM: QUANTITY 3 / Day 03/01/2016 lisinopril,prinivil,z lisinopril estril ADD UM: QUANTITY 1.5 / day 03/01/2016 lisinopril,prinivil,z lisinopril estril ADD UM: QUANTITY 1.5 / day 03/01/2016 lisinopril,prinivil,z lisinopril estril ADD UM: QUANTITY 1.5 / day 03/01/2016 lisinopril,zestril lisinopril ADD UM: QUANTITY 2 / Day 03/01/2016 lisinopril,zestril lisinopril ADD UM: QUANTITY 1.5 / day 03/01/2016 lisinopril,zestril lisinopril ADD UM: QUANTITY 1.5 / day 03/01/2016 mupirocin,bactro mupirocin,mupirocin calcium ban,centany ADD UM: QUANTITY 0.075 / day 03/01/2016 mycophenolate mofetil,cellcept mycophenolate mofetil ADD UM: QUANTITY 1 / Day 03/01/2016 isosorbide mononitrate er,imdur isosorbide mononitrate ADD UM: QUANTITY 1 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 152 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 isosorbide mononitrate er,imdur isosorbide mononitrate ADD UM: QUANTITY 1 / Day 03/01/2016 isosorbide mononitrate er,imdur isosorbide mononitrate ADD UM: QUANTITY 1 / Day 03/01/2016 tamsulosin hcl,flomax tamsulosin hcl ADD UM: QUANTITY 1 / Day 03/01/2016 ramipril,altace ramipril ADD UM: QUANTITY 1 / Day 03/01/2016 ramipril,altace ramipril ADD UM: QUANTITY 1 / Day 03/01/2016 ramipril,altace ramipril ADD UM: QUANTITY 1 / Day 03/01/2016 ramipril,altace ramipril ADD UM: QUANTITY 1 / Day 03/01/2016 fosinopril sodium fosinopril sodium ADD UM: QUANTITY 2 / Day 03/01/2016 fosinopril sodium fosinopril sodium ADD UM: QUANTITY 1.5 / day 03/01/2016 fosinopril sodium fosinopril sodium ADD UM: QUANTITY 1.5 / day 03/01/2016 benazepril hcl benazepril hcl ADD UM: QUANTITY 1.5 / day 03/01/2016 benazepril hcl,lotensin benazepril hcl ADD UM: QUANTITY 1.5 / day 03/01/2016 benazepril hcl,lotensin benazepril hcl ADD UM: QUANTITY 1.5 / day 03/01/2016 benazepril hcl,lotensin benazepril hcl ADD UM: QUANTITY 2 / Day 03/01/2016 pravastatin sodium pravastatin sodium ADD UM: QUANTITY 1 / Day 03/01/2016 pravastatin pravastatin sodium sodium,pravachol ADD UM: QUANTITY 1 / Day 03/01/2016 pravastatin pravastatin sodium sodium,pravachol ADD UM: QUANTITY 1 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 153 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value nitrofurantoin monohydrate/macrocrystals ADD UM: QUANTITY 1 / Day 03/01/2016 nitrofurantoin monomacro,macrobid 03/01/2016 cetirizine cetirizine hcl hcl,children's walzyr,children's all day allergy,children's allergy relief,children's cetirizine hcl,children's allergy complete,walzyr,zyrtec,childre n's allertec,allergy relief,children's zyrtec hives relief,children's allergy,children's zyrtec,all day allergy ADD UM: QUANTITY 5 / Day 03/01/2016 all day allergy,walzyr,allertec,cetirizine hcl,allergy relief,zyrtec,all day allergy relief,allergy cetirizine hcl ADD UM: QUANTITY 1 / Day 03/01/2016 cetirizine hcl cetirizine hcl ADD UM: QUANTITY 1 / Day 03/01/2016 letrozole,femara letrozole ADD UM: QUANTITY 1 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 154 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 HUMULIN 70insulin nph human 30,NOVOLIN 70- isophane/insulin regular, 30 human,nph, human insulin isophane/insulin regular, human ADD UM: QUANTITY 2 / Day 03/01/2016 combi prenatal without iron/folic rx,folbecal,preme acid/calcium sis rx,folinatal carb/pyridoxine/b12 plus b,previte rx,trimesis rx ADD UM: QUANTITY 1 / Day 03/01/2016 ondansetron hcl ondansetron hcl ADD UM: QUANTITY 0.3 / day 03/01/2016 glipizide er,glipizide xl,glucotrol xl glipizide ADD UM: QUANTITY 2 / Day 03/01/2016 sumatriptan sumatriptan succinate succinate,imitrex, alsuma ADD UM: QUANTITY 1 / month 03/01/2016 sumatriptan sumatriptan succinate succinate,imitrex ADD UM: QUANTITY 1 / month 03/01/2016 progesterone,pro progesterone,micronized metrium ADD UM: QUANTITY 1 / Day 03/01/2016 progesterone,pro progesterone,micronized metrium ADD UM: QUANTITY 2 / Day 03/01/2016 ENBREL ADD UM: QUANTITY 0.27 / day 03/01/2016 ketorolac ketorolac tromethamine tromethamine,ac ular ADD UM: QUANTITY 0.167 / day 03/01/2016 dipyridamole,pers dipyridamole antine ADD UM: QUANTITY 4 / Day 03/01/2016 dipyridamole,pers dipyridamole antine ADD UM: QUANTITY 4 / Day etanercept BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 155 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 dipyridamole,pers dipyridamole antine ADD UM: CUSTOM Cumulative: 2 syringes/30 days across inj triptans 03/01/2016 imiquimod,aldara imiquimod ADD UM: CUSTOM Cumulative: 2 syringes/30 days across inj triptans 03/01/2016 imiquimod,aldara imiquimod ADD UM: QUANTITY 0.4 / day 03/01/2016 fluocinonide fluocinonide/emollient base emollient,fluocino nide-e ADD UM: QUANTITY 1 / Day 03/01/2016 enalaprilenalapril hydrochlorothiazi maleate/hydrochlorothiazide de,vaseretic ADD UM: QUANTITY 2 / Day 03/01/2016 enalaprilenalapril hydrochlorothiazi maleate/hydrochlorothiazide de ADD UM: QUANTITY 2 / Day 03/01/2016 acetaminophencodeine acetaminophen with codeine phosphate ADD UM: QUANTITY 2 / Day 03/01/2016 PREMPRO estrogens, conjugated/medroxyprogest erone acetate ADD UM: QUANTITY 1 / Day 03/01/2016 PREMPRO estrogens, conjugated/medroxyprogest erone acetate ADD UM: QUANTITY 1 / Day 03/01/2016 PREMPHASE estrogens, conjugated/medroxyprogest erone acetate ADD UM: QUANTITY 1 / Day 03/01/2016 raloxifene hcl,evista raloxifene hcl ADD UM: QUANTITY 1 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 156 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 myorisan,absoric isotretinoin a,claravis,amnest eem,zenatane,ac cutane,sotret ADD UM: QUANTITY 1 / Day 03/01/2016 absorica,claravis, isotretinoin zenatane,amnest eem,sotret,accut ane,myorisan ADD UM: QUANTITY 1 / Day 03/01/2016 absorica,sotret,cl isotretinoin aravis,zenatane,a ccutane,amneste em,myorisan ADD UM: CUSTOM Cumulative: 4gm/day acetaminophen 03/01/2016 absorica,sotret,cl isotretinoin aravis,zenatane,a ccutane,amneste em,myorisan ADD UM: QUANTITY 1 / Day 03/01/2016 astelin,azelastine azelastine hcl hcl ADD UM: QUANTITY 1 / Day 03/01/2016 loratadine,walloratadine itin,allergy relief,children's allergy relief,children's loratadine,claritin, children's claritin,loratadine hives relief,loratadine allergy ADD UM: QUANTITY 1 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 157 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 loratadine,walloratadine itin,allergy relief,children's allergy relief,children's loratadine,claritin, children's claritin,loratadine hives relief,loratadine allergy ADD UM: QUANTITY 5 / Day 03/01/2016 loratadine,walloratadine itin,allergy relief,children's allergy relief,children's loratadine,claritin, children's claritin,loratadine hives relief,loratadine allergy ADD UM: QUANTITY 10 / day 03/01/2016 allergy loratadine relief,loratadine,w alitin,loradamed,no n-drowsy allergy,allergy,all erclear,vicks qlearquil allergy,claritin ADD UM: QUANTITY 1 / Day 03/01/2016 terbinafine hcl,lamisil ADD UM: QUANTITY 1 / Day 03/01/2016 fluticasone fluticasone propionate propionate,flonas e ADD UM: QUANTITY 0.533 / day terbinafine hcl BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 158 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 pulmicort,budeso budesonide nide ADD UM: QUANTITY 2 / Day 03/01/2016 bisoprolol fumarate,zebeta bisoprolol fumarate ADD UM: QUANTITY 2 / Day 03/01/2016 bisoprolol fumarate,zebeta bisoprolol fumarate ADD UM: QUANTITY 1.5 / day 03/01/2016 SEREVENT DISKUS salmeterol xinafoate ADD UM: QUANTITY 2 / Day 03/01/2016 vitamin b-1 thiamine mononitrate ADD UM: QUANTITY 1 / Day 03/01/2016 leflunomide,arava leflunomide ADD UM: QUANTITY 1 / Day 03/01/2016 leflunomide,arava leflunomide ADD UM: QUANTITY 1 / Day 03/01/2016 ESTRACE estradiol ADD UM: QUANTITY 1.42 / day 03/01/2016 fiorinal with codeine codeine phosphate/butalbital/aspirin/ #3,ascomp with caffeine codeine,butalbital compoundcodeine,asabutalb-caffeinecodeine ADD UM: QUANTITY 4 / Day 03/01/2016 acetaminophencodeine acetaminophen with codeine phosphate ADD UM: QUANTITY 6 / Day 03/01/2016 acetaminophencodeine,tylenolcodeine no.3 acetaminophen with codeine phosphate ADD UM: QUANTITY 6 / Day 03/01/2016 acetaminophencodeine,tylenolcodeine no.4 acetaminophen with codeine phosphate ADD UM: QUANTITY 6 / Day 03/01/2016 butalb-caffacetaminophcodein butalbital/acetaminophen/caf feine/codeine phosphate ADD UM: QUANTITY 4 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 159 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 hydrocodonehydrocodone acetaminophen,lo bitartrate/acetaminophen rtab,norco,lorcet hd ADD UM: QUANTITY 4 / Day 03/01/2016 oxycodoneoxycodone acetaminophen,e hcl/acetaminophen ndocet,roxicet,pe rcocet ADD UM: QUANTITY 4 / Day 03/01/2016 butalbital-aspirin- butalbital/aspirin/caffeine caffeine,fiorinal ADD UM: QUANTITY 4 / Day 03/01/2016 farbital,butalbital- butalbital/aspirin/caffeine aspirincaffeine,fiorinal,b utalbital compound ADD UM: CUSTOM Cumulative: 4gm/day acetaminophen 03/01/2016 zebutal,butalbital- butalbital/acetaminophen/caf acetaminophen- feine caffe,anolor300,alagesic,triad ,esgic,medigesic, capacet,margesic ADD UM: CUSTOM Cumulative: 4gm/day acetaminophen 03/01/2016 zebutal,butalbital- butalbital/acetaminophen/caf acetaminophen- feine caffe,esgic,capac et,margesic ADD UM: QUANTITY 4 / Day 03/01/2016 butalbitalbutalbital/acetaminophen/caf acetaminophen- feine caffe,fioricet,esgi c,repan ADD UM: CUSTOM Cumulative: 4gm/day acetaminophen 03/01/2016 butalbitalbutalbital/acetaminophen/caf acetaminophen- feine caffe,esgic,fiorice t ADD UM: QUANTITY 4 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 160 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name 03/01/2016 butalbitalbutalbital/acetaminophen acetaminophen,t encon,acetamino phenbutalbital,phrenili n,marten-tab 03/01/2016 butalbitalacetaminophen, martentab,tencon 03/01/2016 Type of Change Previous Value New Value ADD UM: CUSTOM Cumulative: 4gm/day acetaminophen butalbital/acetaminophen ADD UM: QUANTITY 4 / Day TAMIFLU oseltamivir phosphate ADD UM: QUANTITY 10 / rx 03/01/2016 TAMIFLU oseltamivir phosphate ADD UM: CUSTOM Cumulative: 4gm/day acetaminophen 03/01/2016 QVAR beclomethasone dipropionate ADD UM: CUSTOM Cumulative: MED 200mg/day 03/01/2016 QVAR beclomethasone dipropionate ADD UM: QUANTITY 0.29 / day 03/01/2016 QVAR beclomethasone dipropionate ADD UM: CUSTOM Cumulative: MED 200mg/day + 4 gm/day Acetamin. 03/01/2016 QVAR beclomethasone dipropionate ADD UM: QUANTITY 0.29 / day 03/01/2016 naratriptan hcl,naratriptan,a merge naratriptan hcl ADD UM: CUSTOM Cumulative: 4gm/day acetaminophen 03/01/2016 naratriptan hcl,naratriptan,a merge naratriptan hcl ADD UM: QUANTITY 0.3 / day 03/01/2016 naratriptan naratriptan hcl hcl,amerge,naratr iptan ADD UM: CUSTOM Cumulative: 4gm/day acetaminophen BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 161 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name 03/01/2016 naratriptan naratriptan hcl hcl,amerge,naratr iptan 03/01/2016 spironolactonehctz,aldactazide 03/01/2016 spironolactonehctz,aldactazide 03/01/2016 Type of Change Previous Value New Value ADD UM: QUANTITY 0.3 / day spironolactone/hydrochlorot hiazide ADD UM: CUSTOM Cumulative: 4gm/day acetaminophen spironolactone/hydrochlorot hiazide ADD UM: QUANTITY 3 / Day amilorideamiloride hydrochlorothiazi hcl/hydrochlorothiazide de,amiloride hclhctz ADD UM: CUSTOM Cumulative: 4gm/day acetaminophen 03/01/2016 amilorideamiloride hydrochlorothiazi hcl/hydrochlorothiazide de ADD UM: QUANTITY 2 / Day 03/01/2016 alendronate alendronate sodium sodium,fosamax ADD UM: QUANTITY 0.133 / day 03/01/2016 erythromycinerythromycin base/benzoyl benzoyl peroxide peroxide,benzam ycin ADD UM: QUANTITY 1.553 / day 03/01/2016 polyethylene polyethylene glycol 3350 glycol 3350,smoothlax, miralax,healthyla x,purelax ADD UM: QUANTITY 17 / day 03/01/2016 lisinoprillisinopril/hydrochlorothiazide hydrochlorothiazi de,lisinoprilhctz,prinzide,zest oretic ADD UM: CUSTOM Cumulative: 9/30 day across oral triptans 03/01/2016 lisinoprillisinopril/hydrochlorothiazide hydrochlorothiazi de,zestoretic ADD UM: QUANTITY 2 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 162 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 lisinoprillisinopril/hydrochlorothiazide hydrochlorothiazi de,lisinoprilhctz,zestoretic ADD UM: CUSTOM Cumulative: 9/30 day across oral triptans 03/01/2016 lisinoprillisinopril/hydrochlorothiazide hydrochlorothiazi de,zestoretic ADD UM: QUANTITY 2 / Day 03/01/2016 lisinoprillisinopril/hydrochlorothiazide hydrochlorothiazi de,zestoretic ADD UM: QUANTITY 2 / Day 03/01/2016 glyburidemetformin hcl,glucovance glyburide/metformin hcl ADD UM: QUANTITY 1 / Day 03/01/2016 RELENZA zanamivir ADD UM: QUANTITY 0.056 / day 03/01/2016 NOVOLOG FLEXPEN insulin aspart ADD UM: QUANTITY 0.667 / day 03/01/2016 zaditor,eye itch ketotifen fumarate relief,wal-zyr,itchy eye,ketotifen fumarate,children' s alaway,alaway,an tihistamine eye drops,allergy eye drops,allergy eye ADD UM: QUANTITY 0.167 / day 03/01/2016 fenofibrate,lofibra fenofibrate,micronized ADD UM: QUANTITY 1 / Day 03/01/2016 glyburidemetformin hcl,glucovance ADD UM: QUANTITY 1 / Day 03/01/2016 omeprazole,prilos omeprazole ec ADD UM: QUANTITY 2 / Day 03/01/2016 pioglitazone hcl,actos ADD UM: CUSTOM 10 per 180 days glyburide/metformin hcl pioglitazone hcl BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 163 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name 03/01/2016 pioglitazone hcl,actos 03/01/2016 Generic Name pioglitazone hcl Type of Change Previous Value New Value ADD UM: QUANTITY 1 / Day omeprazole,prilos omeprazole ec ADD UM: QUANTITY 1 / Day 03/01/2016 pioglitazone hcl,actos pioglitazone hcl ADD UM: QUANTITY 1 / Day 03/01/2016 pioglitazone hcl,actos pioglitazone hcl ADD UM: QUANTITY 1 / Day 03/01/2016 ropinirole hcl,requip ropinirole hcl ADD UM: QUANTITY 1 / Day 03/01/2016 ropinirole hcl,requip ropinirole hcl ADD UM: QUANTITY 1 / Day 03/01/2016 perindopril erbumine,aceon perindopril erbumine ADD UM: QUANTITY 2 / Day 03/01/2016 fenofibrate,lofibra fenofibrate,micronized ADD UM: QUANTITY 1 / Day 03/01/2016 lofibra,fenofibrate fenofibrate,micronized ADD UM: QUANTITY 1 / Day 03/01/2016 oxybutynin chloride er,ditropan xl ADD UM: QUANTITY 2 / Day 03/01/2016 HUMALOG MIX insulin lispro protamine & 75-25,HUMALOG insulin lispro,insulin lispro MIX 75-25 protamine and insulin lispro KWIKPEN ADD UM: QUANTITY 0.667 / day 03/01/2016 verelan pm,verapamil er pm verapamil hcl ADD UM: QUANTITY 1 / Day 03/01/2016 verelan pm,verapamil er pm verapamil hcl ADD UM: QUANTITY 1 / Day oxybutynin chloride BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 164 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date 03/01/2016 Brand Name verelan pm,verapamil er pm Generic Name verapamil hcl Type of Change Previous Value ADD UM: QUANTITY New Value 1 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 165 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change 03/01/2016 allevyn plus,huggies,hug gies pullups,aeroneb go,first aid kit,topiclick,sterile amber glass vial,md pump bottle airless,sterile clear glass vial,megapump airless,humapen memoir,humapen luxura hd,amerigel,innos pire mini,blood pressure monitor,rid,pamp ers premium,omnitro pe pen 5,luvs,pampers ultra dry thin,kimono,guar ds for men,fitted briefs,underpads, overnight protective,pads,sl ip-on,slip on knee,digitex gold,kimono textured,kimono microthin,kimono microthin aqua lube,fc condom, female,kimono maxx,band-aid foam bandage,diaper/brief,infanttoddler, disposable,nebulizer accessories,first aid kit,topical cream metereddose device,vial,empty,insulin admin. supplies,gel dressing/zinc acetate/meadowsweet/oak,n ebulizer/compressor, for nebulizer,blood pressure test kit-large,miscellaneous medical supply,syringe accessory,condoms, latex, non-lubricated,incontinence pad,liner,disp,diaper,brief,ad ult,disposable,underpads,leg brace,gloves,condoms, latex, lubricated,condoms, female,gauze bandage,adhesive bandage,elastic bandage,non-adherent bandage,ostomy supply,colostomy bags,urinary bag,multiple test strip device,blood pressure test kit,pen needle, diabetic,blood-glucose meter,blood glucose calibration control solution, low,blood glucose calibration control solution, high,blood glucose calibration control solution, normal,lancing device/lancets,gel dressing,transfer ADD UM: QUANTITY Previous Value New Value 1.2 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 166 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name gauze pads,band-aid tough pads,bandaid hurtfree,band-aid non-stick pads,innospire deluxe,band-aid secureflex,reliaseal disc,extra colostomy pouch,drainable adhesive pouch,baby urine collector,personal biometric test kit,band-aid waterproof pad,hurricaine dispenser,easy comfort pen needles,true metrix blood glucose mtr,true metrix,sureflex,va scuderm hydrogel wound,embrace evo,varithena administration pack,elasto-gel plus,elastogel,elasto-gel cast-splint padding,ultilet lancets,accuchek safe-tpro,unistik 3,soft set/syringe, disposable/bandages,compr ession/tubing,undercast padding,lancets,lancing device,penile constriction ring systm,vacuum erection device system,bloodglucose calib. control,diabetic supplies,miscell,adhesive tape,blood glucose calibration control high and low,iv equipment,subcutaneous insulin pump,sub-q administration set,needles, safety huber, disposable,iv administration set,insulin pump syringe, 3 ml,needles, insulin disposable,neurological exam pin,peripheral nerve diagnostic device,iv admin extension set-filter,iv admin extension set,soft lens rinsestore solution,needles, filter,blood administration set,blood glucose calibration control solution, high and normal,hydrocolloid dressing,transparent dressing,alginate dressing,iv infusion pump accessory,blood-glucose meter,for mobile device,vaporizer,syringe with needle,disposable,insulin,sy ringe with needle,insulin Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 167 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name touch,accu-chek softclix,pen needles,softclix,a utoject 2,accuchek,rapport ring loading system,rapport vacuum therapy,amielle vaginal trainer,unifine pentips,chemstrip bg diary,1st tier unifine pentips,super thin lancets,aurora super thin lancets,accuchek voicemate,comfor t lancets,unistik 2,lancing device,1st tier unilet comfortouch,pen needle,unifine pentips plus,1st tier unifine pentips plus,allevyn life,allevyn heel,pampers baby-dry,bandaid cloth tape,band-aid paper tape,medlance plus,band-aid waterproof disposable,0.5 ml,syringe with needle,disposable,insulin 1 ml,diaper,brief,adult, disposable,compression stocking,thigh high,regular length,medium,inhaler, assist devices, accessories,inhaler, assist devices,diaper,brief,youth,di sposable,facial mask,compression socks, medium,eye patch,thermometer, temple electronic,thermometer, electronic,oral,wetting soln gas,hard and soft,gloves, latex,hard lens clean-soak solution,soft lens adjunctive solutions,suppository mold,iv venipuncture needle set,irrigation set,tear test,facial-body wipes,iv administration set-clamp,iv administration set-filter,iv administration set,nonvent,container,empty,in-line burette set,iv piggyback adminstration set,iv catheter kit accessory,diaphragms, arc-spring,pump set,diaphragm fitting set,arcspring,anesthesia tray,footcare,miscellaneous, gas permeable lens cleaner,thermometer, electronic,otic,blood pressure test kit medium and large cuffs,blood Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 168 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name tape,band-aid rolled gauze,band-aid mirasorb gauze sponge,band-aid surgipad dressing,microdot ,acti-lance,adriaoncoline,deltec cozmo,huggies pure & natural,deltec cozmo cleo infusion set,unistik 2 normal,unilet gp lancet,unistik 2 extra,gripper plus,infusion,insul in cartridge,adapter, belt clip,easy trak,easy talk,unilet excelite,alternate site lancets,unilet comfortouch,auto pen,ultra thin lancets,lancets,a utolet mini,autosqueeze ,autodrop,neuroti ps,autolet platforms,autolet lite clinisafe,autolet mkii clinisafe,unistik,u nilet excelite pressure test kitmedium,blood pressure test kit-wrist,adhesive remover,pregnancy test kit,walker,silicone adhesive,blunt filter cannula, disp.,petrolatum,white,bismu th tribromophenate/petrolatum, white,blood-glucose meter & wrist blood pressure monitor,dental gingival products,catheter male,external,urinary bag accessories,peak flow meter,colostomy bag, nonsterile,catheter,sanitary pads,procedural tray,contact lens case,soft lens surfactant cleanser,soft lens chemical disinfectnt,soft lens enzymatic cleanser,nasal exhalation resistance device,amniotic fluid detection test,syringe wneedle,disposable,iv catheter kit,nerve stimulator device,iv infusion pump,arm brace,blood administration equipment,transfer sets,syringe with needle, safety, self-cont disposal unit, 5 ml,syringe,needle,insulin,saf ety,disposal unit,0.3 ml,insulin syringeneedle,safety,disposal unit,0.5 ml,syringe,needle,insulin,saf Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 169 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name ii,unilet lancet,neuropen, allevyn gentle border heel,allevyn gentle border multisit,filtered extension set,allevyn gentle border sacrum,microbor e extension set,multi-purpose solution,filter needle,hema ytype blood set,hema blood set,hema blood 30 set,embrace pro,carefine pen needle,allevyn gentle border lite,dermafilmhd,dermaview,de rmaview ii,dermasyn,derm agauze,nitroglyce rin micro pump set,dermadress,d ermalevin,screw cap (40mm) set,dermaginate,li fecare microdrip pump set,dermafilm,sol uset iv micro pump set,bordered gauze,lifecare ety,disposal unit, 1 ml,syringe with needle, safety, self-cont disposal unit, 1 ml,hyperalimentation equipment,dialysis (peritoneal) kits,thermometer, basal glass mercury,thermometer, glass mercury (oral),thermometer, glass mercury (rectal),wadding,blood collection set,incontinence alarms,crutch accessories,cane tips,cane,bed pan,breast shield,cushion,urinal,iv catheter,nebulizer,feeder container with pump set,irrigation piercing pin set,nv,syringe wneedle,disposab,3 ml,back brace,toothpaste,syringe with needle,insulin,0.5 ml,thermometer, electronic (rectal),syringe wneedle,disposab,5 ml,syringe,safety,disp unit,10 ml,syringe, safety, self-contained disposal unit, 10 ml,syringe, safety, selfcontained disposal unit, 5 ml,syringe with needle, safety, self-cont disposal unit, 3 ml,thermometer, basal electronic,syringe, safety, self-contained disposal unit, 3 ml,abdominal brace,syringe Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 170 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name 5000 vial adapter,lifecare 5000 syringe adapter,gmate smart meter,gmate smart starter,transparen t film dressing,clear tape,triaminic flowing vapors,insulin syringe,prevail per-fit 360,gmate voice meter,huggies supreme,huggies ultratrim,protectiv e underwear,huggi es convertible clip strip,huggies convertibles,coba n,paper first aid tape,transpore,3 m nexcare,futuro antiembolism,nexcar e tegaderm,nexcar e gentle paper tape,first choice thin lancets,newborn baby-dry,prevail underwear,allevy n gentle border,supreme w-needle,disposab,1 ml,athletic support,cold-hot pack,swab,sub-q infusion pump accessory,blade lancet, safety,needles, disposable,gauze bandage/lanolin alc/min oil/petrolat/ceresin,infusion set for insulin pump,syringe with needle,insulin disposable,0.3 ml,syringe wneedle,disposab,3ml,draina ge bag,insulin pump cartridge,catheterization tray,syringe, disposable, 1ml,syringe wneedle,disposab,12ml,polyh examethylene biguanide/gauze bandage,compression pantyhose, large,compression pantyhose, medium,compression pantyhose, small,compression pantyhose,x-large,zinc oxide/gauze bandage,compression socks, large,compression socks, x-large,rib belt,syringe with needle, insulin, safety, 1 ml,syringe with needle, insulin, safety, 0.5 ml,dental floss,facialbody sponge,mucus clearing device,incontinence pants, reusable,dressing holder,insulin pump Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 171 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name meter,haemolanc e, retractable,prevai l stretch fit,prevail breezers 360,supreme glucose control,ez spacer & mask,e-z spacer mask,e-z spacer,goodnites, embrace,nexcare all purpose mask,futuro restoring,opticlud e,3m nexcare durapore,3m nexcare stomaseal,microp ore paper surgical tape,stomaseal,bl enderm surgical tape,durapore cloth surgical tape,advanced glucose meter,advanced travel lancets,temple touch prem thermometer,optifree replenish,digital thermometer,viny l gloves,systane contacts,latex gloves,soaclens,t ender tape,clerz controller,calamine/zinc gelatin,dressing, collagen/sodium alginate/carboxymethylcellul ose,thermometer probe covers,stethoscope,incont device,muscle toner,elt,adapter cap for bottle,oral dosing devices,dressing,collagen/sil ver/sod alginate/carboxymethylcellul ose,compression stocking,thigh high,long length,large,hard lens cleaner,hard lens wetting solution,hard lens soaking solution,activated charcoal/iron/sodium/water,s yringe with needle,insulin,0.3 ml,blood glucose calibration control solutions high,normal,low,defibrillator, automatic,external,wet dressing,hearing aid accessory,nasal airflow strips,syringe, disposable, 1 ml,silver,weigh scale,transfer needle,silver/foam bandage,polymerized rosin resin,syringe, disposable, 20 ml,syringe, disposable, 60 ml,denture cleanser,dental adhesive,acne scrub pad,silver sulfadiazine/foam bandage,heating pad,n95 respirator, Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 172 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name plus,optifree,suppository mold,certainty,pri mary piggybackconv,b utterfly,irrigation administration set,schirmer tear test,male adapter plug,wipes,truepl us lancets,micro thin lancets,soluset with cair clamp,male adapter plug w-inj site,dual luer cap,male luer cap,opti-free express,butterfly infusion set,dual injection site,pca set-long minibore,venoset 100 soluset,plum lc 5000 with ivex,rolled gauze,plum lc 5000 microdrip set-nv,plum lc 5000 primary set,pain free wrap,extension set with luer lock,extension set,sharps disposal by mail,plum microdrip disposable,porcine submucosa, fenestrated,ear plugs,finger splint,nonadherent bandage/petrolatum,white,tu bular gauze/tub.rubbr dressing protector,compressor, for nebulizer,ice bag,blood ketone test,strips,pharmacy dispensing adm set,needleless dispensing pin,aloe vera/gloves, latex,pharmacy compounding access.,pen needle, diabetic, safety,syringe filter,needles, pharmacy compound,catheter accessories,external,enteral feeding dispenser, 20 ml,enteral feeding dispenser, 35 ml,enteral feeding dispenser, 60 ml,enteral feeding dispenser,1 ml,enteral feeding dispenser,3 ml,enteral feeding dispenser,5 ml,enteral feeding dispenser,10 ml,transcutaneous electrical nerve stimulators(tens)/electrodes, tens unit electrodes,corn/callus cushion,humidifier,breast pump,iv catheter kit/iv catheter kit accessory,safety seal, for vials,safety seal, for Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 173 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name soluset,plum lc 5000 primary setsl,blood set wpump & cair clamp,blood set 64 w-cair & needle,hemoset 100x10 with cair clamp,iv 3000,venoset piggyback,venos et with cair clamp,veni loop connector,sleep pants,transfer lok,ferrules,self adherent wrap,venoset nv piggybk micrdrp,crimping tool,pentothal dispensing cap,catheter adapter-luer plug,unisol 4 preservative free,pentothal dispensing pin,ortho allflex,iv3000 frame delivery,plum lc 5000 enteral set,well beginnings sleep pants,adi sterile empty vial,pampers cruisers,cont epidural syringes,safety seal, for bags,dental suction device/chlorhexidine gl/dental swab comb no.1,dental suction device/chlorhexidine/dental swab #1/mouthwash,iodoform,prot hrombin time test strips,blood-glucose meter, drum-type,blood-glucose meter, disc-type,bloodglucose meter, wireless,syr biopsy-aspiration reusable,alginate dressing/hydrocolloid dressing,chlorhexidine gluconate,injection ports,sterile field,silver/calcium alginate,spray applicator kit, sterile,silver/hydrocolloid dressing,cellulose,oxidized/c ollagen,activated charcoal/silver,needles, insulin disposable, safety,injector device,ovulation test kit,dental plaque indicator,jejunostomy tube,gastrostomy tube,bacitracin zinc/polymyxin b sulfate,calcium alginate/honey,honey/hydro colloid dressing,diaphragms, contoured,syringe, disposable, 30 ml,infusion set with insulin pump Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 174 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name tray,continuous pediatric caudal,sorespot,c ont epidural wlidocaine-epi,gel bunion guard,cont epidural w-lidoepi-iodin,blood ytype set 66-cair clamp,blood surgical y-type set-clmp,all gel bunion toe spreader,nitrile exam gloves,bladder control pad,crayon bandage,deluxe instant,clear bandages,diaper s,comfortstretch,premium comfortstretch,easy read,conforming rolled gauze,surgical dressing,bandag es,premium baby diaper,premium arm bp monitor,adult wash,adhesive tape,deluxe arm bp monitor,paper tape,premium training body,silver sulfate/foam bandage,needle injector, luer lock, closed system,transfer device, closed system,clamp, iv tubing,connector luer lock, closed system,needle injector, luer, closed system,infusion adapter, closed system,y-site line connector, closed system,assembly system, vial to transfer device, closed system,insulin pump/infusion set/bloodglucose meter,ultrasonic cleaner/holding solution,disinfectant,glycine/ sodium hydroxide,proteaseamylase medical equipment cleaner,vaginal suppository applicator,sub-q administration set, quadfurcated,sub-q administration set, bifurcated,sub-q administration set, trifurcated,syringe, disposable, 5 ml,syringe, disposable, 3 ml,alginate dressing/carboxymethylcellu lose,ringers solution,lactated/gel dressing,mineral oil/aloe vera/petrolatum,white/sodiu m lauryl sulfate,acemannan/alginate dressing,allantoin,eye pressure Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 175 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name pants,flushable cleansing cloths,face mask,detachol adhesive remover,gauze pads,non-stick pad,procare,one step pregnancy test,premium baby wipes,premium nitrile gloves,ultra-light rollator,scar treatment,cloth tape,monoject blunt filter cannula,petrolatu m gauze,xeroform petrolatum dressing,replace ment nebulizer,compre ssor nebulizer,easypro ,duo-care,healthy living,replacemen t air filter,autolet lite,seaband,sea-band for children,one way mouthpiece,comf ort ez,pocketcare irrigator,firstchoic e postop drain pouch,self- monitor,prothrombin time/inr test meter,spirometer with drug delivery adapters,safety syringe with needle, disposable kit-tray, 1 ml,pen injector device,spirometers and accessories,blood-glucose meter,continuous,bloodglucose transmitter,toothbrush,lancet s with blood glucose test strips,diaphragms, wide seal,polyhexamethylene biguanide/non-adherent bandage,polyquaternium6/non-adherent bandage,polyquaternium6/gauze bandage,polyquaternium6/adhesive bandage,bloodglucose sensor,cholesterol test kit,wetting soln gas,hard & soft,alcohol swab cap,rectal, vaginal applicator tip,troche mold,polyvinyl alcohol/gentian violet/methylene blue,vaginal cream applicator,suppository container, empty,filter, disposable ptfe membrane,biosynthetic bandage,urostomy pouch,compression stocking, knee high, regular length, large,gum mastic/storax/methyl salicylate/alcohol,methylene Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 176 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name adhesive catheter,extensio n tubing wconnector,everyd ay self-adhes catheter,insupen, firstchoice drainable pouch,pocket peak,piko 1,premier drainable minipouch,advance hydro,premier pre-sized minipouch,onetouch verio,urinary leg bag,kotex lightdays,spinal22 whitacre wlido-dext,spinal whitacre anesthesia,saddl e block anesthesia tray,saddleblock anesthesia tray,cont epidural w-poviodine,lumbar puncture adult,huggies baby wipes,nutrimix iv empty container,lifecare adds rack,spinal22-bupiv-dexephed-epi,spinal- blue/gentian violet/foam bandage,tubular bandage applicator,eye drops dispenser,ostomy kit,benzalkonium chloride,ear syringe,nasal syringe,iv equipment/container,empty, sub-q insulin pump, continuous glucose monitoring (cgm) syst,diaphragms, flat spring,diaphragms, coil spring,burn dressing,silver na hydrogen zirconium phos/hydrocolloid heel dressing,silver na hydrogen zirconium phos/hydrocolloid toe dressing,home hiv test kit,hot water bottle,ostomy adhesive,vehicle base no. 13,adhesive,colostomy belt,silver na hydrogen zircon phos/hydrocolloid heel&toe/cream59,ostomy cap,wheelchair,eye cup,dental preparation, o.u.,ostomy irrigator,activated charcoal/alginate dressing/hydrocolloid dressing,zinc oxide,feminine syringe,vaporizer-humidifier supply,fountain syringes applicator,rectal syringe,smoking deterrent filter,crutch,thermometer, tape,neck collar,nasogastric tube,compression stocking, Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 177 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name 25-bupiv-dexephed-epi,spinalanesthesia tray,cont epidural-bupivlidocaine,brachial plexus tray,inpersol peritoneal tray,amniocentesi s tray,caudal wlidocaineepinephrine,spina l-22-tet-ephedepi-iodine,nerve block tray wlidocaine,local infiltration wlidocaine,spinal25 w-tetra-ephedepi,kotex,e.p.t.,e. p.t. digital,kotex new freedom,saline solution,sterile presrv,poise pads,sensitive eyes saline,renu saline,sensitive eyes plus saline,depend,de pend guards for men,lens carrying case,daily cleaner,renu multipurpose,sensitive eyes enzymatic,proven knee high, regular length, medium,feeder container wgravity set,compression stocking, knee high, regular length, small,syringe disposable irrig,60 ml,syringe wneedle,disposab,6 ml,syringe, disposable, 6 ml,syringe wneedle,disposb,0.5ml,syring e, disposable, 35 ml,compression stocking, knee high, long length, small,compression stocking, knee high, long length, medium,compression stocking, knee high,long length, large,compression stocking, knee high, long length, x-large,compression stocking, knee high, regular length, x-large,compression stocking,thigh high,long length,medium,compression stocking,thigh high,short length,small,compression stocking,thigh high,regular length,small,compression stocking,thigh high,short length,large,compression stocking,thigh high,short length, medium,compression stocking,thigh high,long length,small,compression stocking,thigh high,regular length,large,compression stocking,thigh high,regular Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 178 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name t,huggies snuggems,goodni te,metercheck,huggies goodnites,amnisc reen,depend fitted brief,surgical pads,depend elastic leg undergarmnt,nor m-ject,cont epidural w-bupivepi,veni-prep ii kit,ezlets,compression shorts,reliefband, two-way transfer device,veni-prep iii-site-care dresng,ivex-2 filterset with ysite,veni-prep i kit,thin lancets,cutinova hydro,durafiber,pl um lifecare 5000 infuser,ace neoprene elbow brace,ace neoprene thigh brace,ace neoprene ankle brace,site-care kit,hema access port,lifecare plum set,lifecare pump set,venoset 78 wmb piercing length,x-large,compression stocking,thigh high,long length,x-large,compression stocking,thigh high,regular length,x-small,compression stocking,thigh high,long length,x-small,surgical suction tubing,feeder container,needles, blood collection,syringe, disposable, 12 ml,syringe with needle, 12 ml,contracept barrier dev, vented,syringe, needle, safety,self-contained disposal unit,1.5 ml,biosynthetic glove,syring w-ndl,disp,insul,0.3 ml/container,empty,syringe with needle, insulin,1 ml and sharps container,nerve test monofilament,porcine acell submucosa,meshed,dressin g, hydropolymer,urinary bag/catheterization tray,calcium alginate,ostomy lubricating deodorant,gel dressing, fenestrated,collagen,bovine, syringe, disposable, 140 ml,gum/polyvinyl alcohol/dental adhesive,gas perm. lens soaking soln,enema bag, disposable,syringe disposable irrigation,gauze bandage/elastic bandage,syringe disposable, irrigation,70 ml,pads for Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 179 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name pin,lifecare pump,ace neoprene wrist brace,plumset speciality pump set-ol,swimmer supporter,dermac ol,venoset secondary,suspe nsory w-o leg straps,nutracol,tr ansfer set,decanting set,nonvented iv set 100 wclamp,nitroglyceri n patient line,soluset 150x15 i.v. setsl,dermastat,scre w cap set,iv pump set-ivexhp,blood y-type pump set,hema blood secondary pump,nutrastat,ai r filter,extension set with stopcock,safesna p syringe,evacuate d container,suspen sory with leg straps,safesnap insulin syringe,ls plum primary setol,plumset primary set- bedsores,peak flow meter/inhaler, assist devices,colostomy washer,ostomy disinfectant,karaya gum,syring wndl,disp,insul,0.5 ml/container,empty,colostom y-ileostomy sets, nonsterile,urostomy sets, nonsterile,colostomy-ileostomy sets, sterile,urostomy sets, sterile,syringe, irrigation, reusable,needles, spinalanesthetic,syring w-needl 0.5 ml,kit-tray,syringe with needle, 0.5 ml,syringe with needle 1 ml, disposable kittray,syringe, disposable, 10 ml,syringe w-cannula,disp, 3 ml,syringe w-cannula, disp, 5 ml,syringe wcannula,disp, 10 ml,syringe with needle/cannula,disposable 10 ml,blunt needle, disposable,syringe,safety with needle,5 ml,syringe,safety with needle,10 ml,syringe,safety with needle,1 ml,needles, safety,syringe, disposable, 2.5 ml,syringe,safety with needle,3 ml,syringe, disposable, 50 ml,lumbar supports,needles, reusable,needles, huber reuse,needles, huber disposable,syringe reusable, Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 180 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name ol,dermasite,allev yn tracheostomy,dial -a-flo microdrip set,safesnap allergy syringe,dial-a-flo iv extension set,venoset sec piggyback,nutrimi x,inpersol w-o auto shutoff valv,inpersol-auto shutoff valve,abbott counting tray,blood set,cvp universal set,syringe filter,anesthesia extension set,sanitizer bottle,adult supporter,nonven ted primary pg-bk w-cair,backcheck extension set,blood set 82sl,blood set 78-sl, y-type,venoset secondary piggybk set,venoset t-type w-cair clamp,drumcartridge catheter,insumed ,fever thermometer,butt 5 ml,syringe reusable, 2 ml,syringe reusable, 50 ml,syringe reusable, 3 ml,syringe reusable, 20 ml,syringe reusable, 30 ml,syringe reusable,syringe reusable, 10 ml,syringe reusable, 1 ml,needles, biopsy,bone,aspirate,syringe reusable, 0.25 ml,myelogram tray,syringe with needle,insulin 0.3 ml (half unit mark),cholesterol test, strips,cholesterol calibration controls - high and low,cholesterol & blood glucose meter,dressing, odor absorbent, hydropolymer,syringe with needle, 10 ml,gel-matrix pad dressing, silicone/benzalk chl/vit e/min oil,syringe w-o needl,insulin,1 ml,needle clipping and storage device,pen needle, diabetic disposable, safety,hard lens soak-wet solution,feeder irrigation kit,y-port adapterextension set,syringe,safety with needle,12 ml,syringe wneedle,disposab,6ml,syringe w-cannula,disp, 6 ml,syringe with cannula,disposable 12 ml,syringe with needle, insulin, safety, 0.3 ml,hard contact lens enzymatic cleanser/pf,mercury spill clean-up kit,medical information identification Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 181 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name erfly s.t. 19x7/8.31/2tbg,provider pump set,pca injector,ace rubber elastic bandage,curity wet-pruf adhesive tape,curad super soft puffs,curity curad adhesive bandages,curad gauze pads,cvp manometer,curad stretch gauze bandage,ivex-rf filter set,tidal joint irrigation tray,cont epidural tray w-drugs,cont epidural-lido-epi t-dose,spinal anesthesia tray,spinal-22 wbupiv-epiephed,secondary set,pump set wproximal male adapt,flip-top additive cap,butterfly st,tru-touch gloves,venous cannulation tray,blood set wcair clamp,durall,bloo d collection set,wet- tag,foam/gauze bandage/lidocaine/chlorhexi dine/isopropyl alcohol,adhesive bandage/adhesive tape/benzalkonium chloride,adhesive bandage/adhesive remover comb. no.1,hydrocolloid dressing/adhesive remover comb. no.1,dressing, foam matrix/activated charcoal,blood pressure test kit-small,blood pressure kitextra large,head support, infant, small,head support, infant, medium,silver sulfate/non-adherent bandage,head support, infant, large,blood-glucose and blood pressure beter with adult cuff,foam heel dressing,middle ear inflation device,sub-q insulin delivery device, 20 unit,disposable,sub-q insulin delivery device, 30 unit, disposable,sub-q insulin delivery device, 40 unit, disposable,blood glucose and ketone control, normal,conception assistance supplies combination no.1,syrng wndl,disp. kit-tray,1ml,bloodglucose transmitter/bloodglucose sensor,syrng wndl,dsp kit-tray,0.5ml,syringe w-cannula,disp, 1 Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 182 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name stop,kerlix,primar y iv set-sl with ivex-hp,crutch tip,batteries, six volt (pair),crutch pad,pca minibore,hand grips,cane tips,knee support,venoset dual-rate pgbkivex-2,walker tips,burette nv inline set wport,500ml pressure infusion cuff,pressure infusion cuff,nonvented secondary iv set,cane,bedpan,i vex h.p. pediatric exten set,nursing pads (breast),cervical traction kit,wheelchair invalid ring,wheelchair cushion,venoset piggyback-mb pin-clmp,sitz bath,urinal,cervic al pillow,curity telfa non-stick pads,primary piggyback nv ib set-sl,abbocatht,sports ml,syringe, disposable,blood-glucose meter,continuous/bloodglucose transmitter,blood sugar diagnostic test strips with disposable meter,chemo gowns,smocks,plastic bags,cervical cap,insulin pump syringe, 1.8 ml,isopropyl alcohol,chemo spill clean-up kit,sodium chloride,fecal collector with charcoal filter,incontinence bed sheets,covers,syringe w/needle,insulin disposable 0.3 ml (half unit mark),propylene glycol,ovulation and pregnancy test kit,mineral oil/non-adherent bandage/petrolatum,hydrop hilic,disinfectant liquid soap cmb4,thermometer, infrared, non-contact,toe splint,ring,transcutaneous electrical nerve stimulators (tens units),cath male external-starter kit,dental polish-varnishes,venous flow controller,needles, subcutaneous set,iv administration set/needles, reusable,ostomy accessories, filters and bridges,feeding pump,gravity feeding set,ring pessary,fecal collector w-charcoal Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 183 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value tape,curity telfa filter/catheter/syringe, adhesive dispos,needleless accessory pads,curity device, insulin nursing pads,sport neoprene,cvc kit,sport polartec,venoset piggyback w-ivex filtr,tennis elbow support,lifecare shelf storage tray,neoprene knee stabilizer,replicar e,tegagen hg,allevyn thin,tegagen hi,fortiscare blood glucose syst,replicare ultra,nv cardiac catheter set,tegaderm,mic robore extension set-sl,manifold 111sl,ventstream nebulizer,zoey,pc a cont inf minibore,pca set-cont inf mini bore ol,pca extension set,pca set-long mini bore ol,nonvented t-u-r set,t-u-r system w-flow pouch 2000,cystoscopyBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 184 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value irrigation set,catheter wcair clamp nonvent,access set,secondary irrigation set,cystomanome ter set,nv large bore y-irrigation set,quicktek,exte nsion set-locking luer t,blood warming coil,thoracentesis set,inpersol peritoneal cath. 11fr,y connector,double -needle transfer device,selectlite,additive hinge cap,assure 3,pocketchem ez,lifecare additive cap,assure pro,advance microdraw,advance,ste rile empty vial,inline burette set,replicare thin,micropore,qu ik lok luer lock adapter,durapore ,sterile empty vial& injector,cicacare,anti-stick BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 185 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value insulin,anti-stick tuberculin,ace velcro bandage,vanishp oint,4 leg nonvented transfer set,3 leg vented transfer set,ace back support,4 leg vented transfer set,tartar control,truedraw, sensitive teeth,fever thermometerimprinted,clearcath,16g,1-1/4 in,clearcath,20g,2 in,sheer spot bandages,s-a-i-f set 1 micron,blood glucose monitoring,ivex h.p. filterset,platelet concentrate infusion,sensicar e,extension tube,clearcath(subclav),saf esnap tuberculin syringe,clearcath,tru-fit knee support,premium blood glucose,ace BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 186 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value plastic gloves,sentinel thermometer,ther mometer,abbocat h-t with syringe,basal thermometer,ace neoprene plus knee brace,threeway stopcock wluer lock,threeway stopcock ext 20-sl,ace neoprene knee brace,three-way stopcock ext 36,three-way stopcock,ace ankle brace,ace tennis elbow brace,ace neoprene ankle wrap,three-way stopcock ext 20in-sl,ace elastic bandage,ace wrist brace,ace knee brace,ace elbow brace,autolancet,ace unibody supporter,ace athletic supporter,ace plus rigid wrist brace,ace swim supporter,pca BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 187 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value mini-bore set,ace cup supporter,ace plus knee brace,ace bandage clips,ytype connecting set,ace elbow strap,ace athletic bandage,extensio n set intsl,venoset 78 wivex-2 nonvented,ace knee strap,ace sports underwrap,ace reusable cold compress,syringe with needle disp,ace instant cold compress,ace hot-cold compression wrap,ace hot-cold compress,pharm acy additive transfer set,ace sports tape,swabs,accuchek tender,accu-chek rapid d,j & j first aid kit,accu-chek spirit,triangular bandage,antisepti c wipes,rescue blanket,bandBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 188 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value aid,instant cold pack,elastic bandage,gauze sponge,assure haemolance plus,cotton balls,haemolance plus,steripak,sew -in pocket,healthcare gloves,techlite blood lancet,techlite,tec hlite lancets,johnson's health care gloves,johnson & johnson filter mask,sof-wick drain sponge,bioclusiv e,assure lance,sof-band bulky bandage,sofwick,elastikon,ha emolance,novofin e plus,proxistrip,adaptic,ulcer dressing,glucocar d xmeter,release,ey e pad,glucocard vital,surgipad,nugauze sponge,glucocard 01 control,kling rolls,glucocard xmeter BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 189 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value control,glucocard 01,topper dressing sponge,glucocard expression,assur e 4,glucocard 01mini,multi-lancet device,first aid tape,assure platinum,dermicel ,waterproof tape,advance intuition,adhesive pads,assure dose,non-stick pads,hypolance,f ora v12,foracare gd40a,foracare gd40b,fora g71a,control solution,premium v10,fora v30a,choicedm g20,nursing pads,foracare gd20,curity,fora test n'go voice,versalon,te ndersorb,plum lc 5000 minipole,hypoder mic needle,lifecare 5000 secondary cntnr,monoject insulin syringe,curagel,d urasorb,microdrip micro pump setBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 190 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value filtr,cuticerin,pedi atric microaggr blood filt,megapumpblue,excilon washcloth,burette 100ml hemoset nv,accu-chek ultraflex,simplicity pants,blood set w-pump-sl,accuchek ultraflex ii,monoject syringe,venoset 100-sl piggyback nv,snap lock device,curity maternity belts,lifecare flex container,curity abdominal,fora gd50,lifecare flex container 1000ml,suretys,fl exlink plus infusion set,container with y-transfer,curity urethral catheter,sharpsa-gator disposal system,nutriclamp,urinary drainage bag,dtronplus adapter,accuchek d-tron plus,insertion tray with pvp,nutrimixBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 191 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value macro ferrules,irrigation sleeve,sport belt,extra openend drain,empty 3-in-1 mixing container,monoje ct tb,multipurpose contact lens soln,curity underpads,curad kid size bandages,saline sensitive eyes,curad ultralite,curity curad flexible fabric,curity amd,knee comforter,curity curad flexible bandages,excilon amd,beyond support,single shot epidurallidocaine,blood ytype set wpump,blood set 64 with cair clamp,compressi on pantyhose,blood set 78 with cair clamp,primer modified unna boot,suspensory, cup supporter wprotector cup,fortiscare,athl BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 192 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value etic supporter,pca plus 2,compression stockings,lifecare 75 flow detector,surgical stockings,lifecare micro pump,controller lifecare model 75,lifecare micro pump 1a,i.v. stand-pole assembly,super socks,i.v. clip adapter,i.v. stabilizer bar,dual i.v. stand adapter,i.v. stand-base assembly,soluset -ivex-2 filter & cair,wrist brace,elbow brace,knee brace,nonvented iv set 100 with cair,surgical binder abdom support,sacroiliac brace,herniaaid,lc 1050 controller,lifecare 1025 controller,flow detector 54inch,flow detector BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 193 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 30inch,ankle brace,venoset microdrip,back support,rib belt,nighttime underpants,ultilet classic,wrist brace reversible,prevail per-fit,wrist brace splint,assure id insulin safety,pouch arm sling,dtron,prevail,h-tron power pack,lancets thin,lancets ultra thin,cartridge filling aid,arm belt,lifecare 1050 drop detector,enteral set with container,steripad,cotton rounds,nugauze,dental floss,dental floss waxed,dentotape ribbon floss,stimu-dent,telcare bgm,pregnancy test,buf bodymate,flutter, dignity natural extra,dignity underpad,dignity diaper,dignity BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 194 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value regular,dignity regular duty,dignity extraduty,dignity,free & active super,prevent plus,briefmates,la dy dignity plus brief,dignity plus regular brief,sir dignity plus brief,dignity plus,dignity plus liners,elon nail care system,dignity plus fitted brief,snap insulin pump controller,inspirea se,dome-paste bandage,biostep, allevyn,reality,de pend belted shields,poise,alle vyn adhesive,huggies overnite,huggies newborn,thermo meter probe covers,babyther m pacifier thermometer,stet hoscope,pelvic muscle trainer,precisedo se dispenser tip cap,incontinent liner,underpad,pr BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 195 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value ecisedose dispenser syringe,dermagra n,md pen airless,md syringe airless,md jar airless,biostep ag,ems antiembolism stocking,compact space chamber plus,compat yset,space chamber plus,easy touch pen needle,athletic tape,healthpro glucose monitor,healthpro glucose control soln,lady lite,hard contact lens cleaner,hard contact lens wet,hard contact lens soak,new freedom lightdays,kotex security,lil swimmer small pant,lil swimmer large pant,lil swimmer medium pant,protective pads,ear thermometer,heat wraps,hot-cold BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 196 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value compress,arm sling,myglucohea lth,on call express control soln,on call express meter,autolancet device wlancets,on call plus meter,ultratlc lancetsdevice,heartstrea m fr2,bladder control pad ultra,insultote,blood glucose monitor kit,bandage,stretc h bandage,adhesiv e bandage,sheer strip,absorbent cotton balls,supreme diapers,diapers mega,jumbo diapers,gmate voice starter,kidpant,tra ining pants,instant cold therapy wrap,sleep comforts,underw ear,gentle tape,baby wipes,md pump actuator a,diaper,md BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 197 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value pump actuator b,hearing aid batteries,probe covers,nasal strips,plastic swabs,guard male,briefs xlarge,selfadhering,cleansin g wipes,on call vivid pal,luer slip tip syringe tray,overnight briefs,on call vivid meter,maxi pads,gloves,actic oat,non-adhesive pad,sheer bandages,exacta -mix,ohaus scout sc,myglucohealth lancets,myglucoh ealth control solution,iv transfer needles,exactamed,acticoat surgical,venting pin,sure-test easyplus mini,surelance,sure-ject insulin syringe,surepen,sure-fine pen needles,stik it,autolet lancing device,unilet lancets,bandage BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 198 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value roll,butterfly closures,amber oral-topical syringe,caresens prem lancing device,slip-tip syringe,carelance ult lancing device,suretouch,luer slip tip cap,luer-lock syringe,kendall foam border,temple thermometer,up & up baby diaper,wonderpa nts,up & up maxi pads,sudacare advanced,pediac are gentle vapors,efferdent plus,telcare,effer dent,fresh'n brite,effergrip,telc are control solution,accuchek nano smartview,nessi spacer,2tek,actic oat flex 3,e.p.t. stick test,e-z spacer pedspak,buf-puf bodymate,bufpuf,allevyn ag,buf-puf gentle,selfgrip,buf -puf BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 199 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value sponge,elastic stretch net,prestige smart system iq,women's underwear,men's underwear,brief,c ontact lens case,household burn kit,heating pad,reusable instant heat pack,purple nitrile gloves,actiprotect uf,overnites diaper,flex fabric bandage,adhesiv e gauze pad,allevyn ag gentle,oasis ultra,flex bandage,extra absorbent undergarment,ey e patch,disposable latex-free gloves,saline 4,weekly vitamin planner,ear plugs,contact lens relief,alkaline batteries,procedu ral face masks,suresite window,finger splint,all-purpose BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 200 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value dressings,surgica l dressings,nonstick dressings,advanc ed non-stick dressings,tubular gauze,gauze sponges,dressing sponges,devilbiss pulmomate,pulm o-aide,x-abs underwear,devilbi ss compact,devilbiss pulmo-aide,cold pack,devilbiss disposable nebulizer,novama x plus,ultilet pen needle,sunrise compressornebulizer,devilbis s traveler,dual rate syringe infuser,bifurcated fluid tran tube set,cytosafe dipensing pin,elbow inlet,saline sensitive,vial adapter,fluid transfer extension set,aloe vera latex gloves,gravity mixing set,luer lock-to-bag,bag BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 201 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value spike,gauze bandage,oral liquid transfer tube set,dual rate syr infuser tubing,flexible dressing,calibrati on bag,fluid transfer set,stretch gauze bandage,micro volume inlet,pole clamp,adhesive dressing,microfus e minibore,earloop mask,temple touch mini thermometer,mini bore,selfadherent gentle wrap,em2400 valve set,exactamix calibration,exacta -mix eva,micromacro,s terl fluid transfer tube set,topical tip cap,topical cream dispenser,novofin e 32,novopen 3,topical dispenser,syringe filling fixture,sterile fluid tran tube set,novopen jr,repeater pump BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 202 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value stand,innovo,oral liq bag-tube set combo,novofine,0 .2 micron filter attachment,phar macy pump stand,novotwist,n ovofine autocover,sterile exacta-med dispens-pin,gel bag & tube set non-sterile,sterile top fill bag,tamperresistant bag cap,adaptacap,blood pressure cuff,sterile empty collection bags,trifurcate fluid tran tube set,microfuse,pha rmacy pack liquid dispenser,cotton swabs,nordipen 5,nordipen 15,exacta-med tip extender,supor,st erile two-fer needle,sterile rapid fill connector,sterile gel bag,luer to urethral tip adapter,luer to catheter tip BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 203 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value adapter,repeater pump,vaginal cream dispenser,premiu m adult wash cloths,exactamed tip cap,luer lock tip cap,port saver sterile inject port,vaginal dispenser tip cap,tip caps, nonsterile,mark-adose,oral labels,qwikstrip,shrinksafe,3way oral port stopcock,rapid fill adapter,sterile rapid fill adapter,oral-tooral rapid fill connec,t.i. seal non-sterile foil,kwikvial,bottle adapter,labels, 1.5" x 1.5",kwikvial plug dispenser,portabl e sharps disposal,kwik-vial filling extension,triple layer non-stick pad,self-righting luer slip tip,selfrighting luer tip cap,self-righting BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 204 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value luer lock tip,clip & stor,heartstart,art hritis heatwraps,peas cold therapy,luer slip tip caps,sterile luer slip tip caps,luer lock tip caps, sterile,catheter tip cap,locking,neoth rive,icy hot smart relief tens,ward pack liquid dispenser,icy hot smart relief tens pads,calcium alginate,hydrogel dressing,bedside pack liquid dispenser,hydroc olloid dressing,heat therapy patches,rapidfill,all purpose cloth tape,corn cushion,flex finger bandage,callus cushion,foam toe bandages,molesk in plus,humidifier,ad vocate lancet,nebulizer, water-proof bandages,plastic strip,biovue,allev BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 205 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value yn ag adhesive,allevyn sacrum,barrier,sp hygmomanomete r,prevacare,prepti c,chix,sofnet,daylee,barrier fenestrated strl field,preptic shave prep,preptic 2 shave prep,filters,mask,l ister's suture removal kit,protectiv,breas t pump,entrust plus undergarment,pr otectiv plusw,protectiv-w,sofloop,barrier n95,surgine,surgin e ii,microtouch,microtouch xp,neutralon,max xus,neutralon 50,steritamp,coverlet o.r.,allergard,micr o-touch pf,maxxus pf,assess peak flow meter,personal best peak flow meter,blairex sterile saline BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 206 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value soln,mirasorb,ultr alon pf,comfort bath,toothette,qcare rx,iv prep antiseptic,exel syringe,coaguche k,insulin pen needle,accu-chek safe-t-pro plus,easymax n,easymax,truepl us insulin syringe,compat gravity delivery set,compat enteral delivery pump,breeze 2,first aid paper tape,contour link,first aid waterproof tape,glucolet 2,first aid cloth tape,fingerstix,as censia autodisc,first aid skintone paper,autodisc normal,first aid plastic tape,singlelet,true2go blood glucose system,microlet, microlet 2,cold comfort,didget,co ntour next link,germ filter protective BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 207 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value mask,dust & pollen filter mask,air warming mask,contour,tru eresult blood glucose systm,contour next control solution,contour next ez,contour usb,contour next,contour next usb,bandages sheer,rolled absorbent cotton,sterile pads,needle collection & disposal,astrapro, cartridge dispenser dental,astra selfaspirating dental,topper,tiell e plus,dermiform,kli ng fluff,kling conforming gauze bandage,dynaflex,sof-kling,raytec,sof-foam,wrist immobilizer,pantili ners,fibracol,algo steril,nu-gel collagen,nugel,band-aid island surgical,zonas,de BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 208 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value rmiview,deluxe wrist brace,ultra thin,biopatch,nubrede,bioclusive select,tielle,bioclu sive mvp select,bioclusive select mvp,inhaler companions,asth ma control,interlink,b arrier sterile field,healthy accents unifine pentip,pentips,sil vercel,fine 30 universal lancets,zymogen etics spray applicator,vicks warm steam vaporizer,health mist,thermoscan, vicks digital thermometer,vick s forehead thermometer,vap orizer,vicks cool mist,vicks warm mist,silverseal hydrogel,promogr an prisma,promogra n,actisorb,solutio n transfer device,drymax extra,iv administration BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 209 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value set,adult aerosol mask,reconstitub e,tablet cutter,healthy accents unilet lancet,healthy accents autolet,deluxe tablet cutter,autolancet mini,injectease,insuleze,insulcap,insultray,ovulation predictor,flexicha mber,hurriview ii,hurricaine spry extension tube,hurricaine luerlock,tegaderm hydrogel,hurrivie w,beutlich ph test,trueresult blood glucose meter,thumb support,optumrx,t ranquility premium underwear,accuchek aviva connect,baby darlings diapers,clear glass serum bottle,goodnites tru-fit,vivonex jejunostomy kit,compat,compa BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 210 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value t container wpump set,compat select flo pump,compat select flo case,compat select flo baggle cage,new image closed pouch,caresens n,caresens,cares ens n voice,huggies overnites,little darlings,options pads,early ovulation test,options liners,options ultra thins,comfort,eas y touch,easy touch fluringe,medlance plus special blade,easy touch insulin safety,band-aid plus antibiotic,mediho ney,dermagran hydrophilic wound,nite train'r,medihoney hcs,ulticare pen needle,ulticare,bo ston cleaner,boston conditioning BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 211 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value solution,caya contoured,flexible fabric bandages,gentlec ath,esteem drainable pouch,comfort short,well beginnings training pants,simplicity,a gamatrix amp,clickfine,tear flo,advocate lancing device,ezvac,argyle,luerlok tip syringe,sure comfort,snap insulin pumpinfusion set,urocare fabric leg straps,medilance,aurora healthcare lancets,lite touch,esteem+ closed pouch,esteem+ durahesive plus,esteem+ drainable pouch,mefix,mepi lex border,mepilex,m epilex border sacrum,mepilex ag,phaseal BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 212 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value injector luer,phaseal protector,phaseal infusion,phaseal connector luer,phaseal secondary set,aerochamber plus flowvu,esteem synergy drainable pouch,phaseal adapter,phaseal y-site,phaseal assembly fixture,natura drainable pouch,comfeel,st erile nitrile gloves,amber glass serum bottle,protection plus,aquacel-ag extra,aquacelag,amber glass bottle,power cleaner,cetylcide g,hyde-out,luer lock syringe,cetylzyme,replacemen t j-4 cannula,vaginal suppository applicator,gluco navii,skintegrity,g rx wound gel,thermacare,el ement compact BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 213 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value control soln,eakin cohesive,neria multi,element compact,telfa,kan garoo 924 safety screw,evencare mini glucose control,evencare mini monitor system,easy comfort insulin syringe,luer-lok syringe,fora control solution,t:slim,t:fl ex,luer tip cap tray,onetouch delica,maxorb,ma xorb extra,medfix,optif oam,exuderm rcd,exuderm ultra,exuderm,ex uderm sacrum,dermagel,exuderm lp,ez smart,tens replacement body pads,tens replacement back pads,tenderwet,e z smart lancets,ez smart plus,tenderwet active,universal 1,suresite flexigrid,suresite, cool mist humidifier,suresit BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 214 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value e iv,dry time training pants,arglaes film,arglaes,argla es island,dermal wound gel,ultraklenz,t:90,carras mart,primary dressing,incontin ence skin care,carraginate, carradres,radiadr es,t:slim g4,stratasorb,pu mp for whirlpool solution,shampoo & body wash dispenser,carra sorb h,carra film,carra sorb m,diab,radiafdg,c arrasyn gel,gel pad,wound dressing,gauze packing strip,carrasyn spray gel,carra gauze strips,carra gauze,carrasyn v,carracolloid,pro view eye pressure monitor,onetouch ultra2,pep nebulizer,pep pressure monitor,bubbles the fish,lc BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 215 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value nebulizer,coaguc hek xs,truzone peak flow meter,trek s compact compressor,mout hpiece for truzone peak fl,adapter w-disp mouthpiece,mout hpiece,proneb,m ask, pediatric,onetouc h ultralink,onetouch ultra smart,onetouch ultra control soln,surestep pro,surestep control solution,onetouch ultramini,well beginnings diapers,true metrix air glucose meter,onetouch ultra system,onetouch verio iq,onetouch suresoft,onetouc h lancets,surestep, one touch basic system,penlet plus blood sampler,one touch glucose control BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 216 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value soln,onetouch finepoint lancets,one touch verio,one touch delica,mistassist kit,easy touch fluringe flu tray,easy touch syr allergy tray,humatropen, mistassist,dexco m g5,brush 'n floss,allergy syringe,alligator spoon,fora v10v12-d10d20,prevail smooth fit,prevail curve,pro-ception fertility pak,wide seal diaphragm,sheer bandage,td gold level 1 control sol,td gold level 3 control sol,td gold level 2 control sol,aquacel ag foam heel,aquacel ag foam sacral,aquacel ag foam,aquacel foam sacral,dexcom g4,td gold blood glucose monitor,topcare maxi pads,td gold BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 217 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value voice glucose monitor,reliamed, rightest gc250s control soln,curad,topcar e pads,topcare pantiliner,element compact v,fora test n'go bp,sidestream,pa mpers rash care,luvs overnight,pamper s premie,hydress,p ampers,pampers ultra dry,fc2 female condom,underja ms,liqua spen,pampers newborn,on-thego,safety lancets,pampers easy ups,diatrue,uroca re urinary drainage,uro-con catheter,diatrue plus,pampers extra protection,washcl oth,pampers premature,pampe rs preemie,pampers swaddlers,pampe rs swaddlers sensitive,eyelid BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 218 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value cleansing pads,bioguard nonadherent,bioguar d packing,bioguard island,pampers unisex,bioguard gauze,depend protection,lavend er nitrile exam glove,aimsco,aim sco ultra thin ii,aimsco mini ultra-thin ii,ultrathin ii,ultra thin ii,ultra-thin ii lancets,goodnites sleep shorts,esteem synergy+,relion thin,poise liners,depend overnite,smart sense monitoring system,depend silhouette,depend real fit,minimed 530g,kotex overnight,enlite serter,kotex fresh & dry,assure prism multi,glucocard shine,assure lance plus,venoset 100 piggyback wclamp,soluset wBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 219 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value pediatric ivex sl,pca pump,rightest gm250s meter,rightest gm260 meter,lifecare model 4 macro pump,lifecare controller model 1000,topcare male guard,screw cap set 38mm,ivex-hp administration set,venoset-100 prim pigbk-ivexhp,topcare liners,fat emulsion iv set,advocate pen needles,primary iv set-sl,ls plum secondary setol,nylon epidural catheter,primary pump set,enlite glucose sensor,prevail brief,cutiepants,p rodigy autocode,topcare maxi overnight,devilbis s pulmoneb lt compneb,topcare belted shield,topcare BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 220 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value underpad,advanc ed care cholesterol test,inspirachamb er,orthodiaphragm,steritamp seal,clerz-2 lubricatingrewetting,gmate control solution,gmate lancing device,clerz2,gmate,bardex lubricath foley,vial,sterile,e mpty,iv transfer spike,maxifill transfer set,md pump actuator c,sleep overs,cuties,refua h plus,refuah plus glucose control,unisol 25 day p-f saline,mirasept,m irasept step 1,mirasept step 2,opti-clean ii daily cleaner,preflex,u nisol plus,optione multipurpose,opticlean daily cleaner,flexcare,saline for sensitive BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 221 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value eyes,alcon enzymatic,optisoak conditioning,optitears,opti-soak daily,opti-soak soothing drops,depend shields for men,algisite m,fact plus pregnancy test,algicell ag,ultra + pampers,pamper s thick phases,pampers ultra phases,pampers nonelasticized,adapt er cap,huggies slipon,lanzo,kendall disinfectant cap,thermometer tip covers,universal syringe tip adaptor,transfer pin,dover latex foley catheter,hivolume pumping chamber,mini transfer pin,floweze,chemo transfer pin,easy comfort,aeroneb go BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 222 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value nebulizer,belted undergarment,me pitel,blood pressure kit,syringe tip rectalvaginal,troche mold,supposistrip ,hydrofera blue,pcca accupen15,unistik safety,universal sleeve,vaginal cream applicator,suppos itory box,clearblue,bos ton round natural,filter, millex-or syringe,bottle,filte r, millex-fg 0.2um,luer lock adapter,supposit ory shell, medium,supposit ory shell, small,ascensia elite,flexzan adhesive dressing,hydrocol ii,sorbsan,biobran e-l,biobrane dressing,biobran e-l dressing,apogee hc intermittent,estee BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 223 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value m synergy,boules quies earplugs,relief knee open toe,mastisol,mast isol adhesive,freedo m precision airless,hydrofera blue ready,precise pain relieving,push button safety lancets,tubigrip,tu bular bandage applicator,tubipad ,lyofoam,pump for liquagel,lyofoam c,lyofoam t,lyofoam extra,lyofoam a,kaltostat,sterile droptainers,sur-fit natura post op,eakin skin barrier,eakin fistula & wound pouch,stomahesi ve,dexcom g5-g4 sensor,polymem, gentle touch system,gentle touch loop ostomy sys,saline,antibac terial bandage,advanc BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 224 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value ed antibacterial bandage,antibact erial pad,assure prism,child ear syringe,foam ear plugs,nasal aspirator,infant ear syringe,empty viaflex container,empty viaflex-y-transfer set,sub-q set,versiva xc,sensi-care adhes remover wipes,watchhaler ,animas vibe,fever flash thermometer,fast read thermometer,eas y-touch insulin syringe,condoms, ultra comfort,nutriclamp w-transfer set,opti-one,optifree lens case,advance pregnancy test,pliagel,exudry,conformant 2,opsite iv 3000,drynet,repli care ultra sacrum,aerocha mber with flowsignal,acticoa BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 225 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value t 7,acticoat absorbent,aquap hor gauze,hydro armor ag,coverlet eye occlusor,ice it!,thermophore maxheat,thermop hore,comp-air nebulizer compressor,thum b stabilizer,deluxe wrist stabilizer,thermop hore arthritis,skinprep,a.i.r.s. nebulizer,unisolve adhes remover wipes,no-sting skin-prep swab,solosite,exu -dry slit tube,hot & cold wrap,clear spots,fabric bandages,sheer adhesive,antibact erial bandages,cone masks,bed underpads,contro l pads,dosage syringe,dosage dropper,ice bag,fancy pill box,7 day pill box,daily pill box,dosage BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 226 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value spoon,one weektoday,pill pal,rubber finger,adult brief,youth brief,glass graduated cylinder,prevail fits to a t,ultrathin,posidyn e eld,megapump mezzo,xtremefit brief,pant liners,pant liner large,washcloths, adult frontal tape brief,prevail premoist bath cloth,attends washcloths,rectal -vaginal perforation tip,tuckables,topiclick filling nozzle,enema bottle,securely yours,home access hiv-1 test system,ezsorb,quickables washcloths,prote ction plus classic,ultra-soft plus,protection plus underpad,ultrasoft classic,adheres,u ltima BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 227 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value incontinence,tuffs orb,ultima tuckables,microle t vaculance,cairpa d,primabella,realtime starter kit,adapter pressin bottle,syringe filter, millexgs,suppository shell,thong liners,ear syringe,tampons, undergarment,ba by darlings wipes,combinatio n water bottle,water bottle,pure cotton,oral syringe,truetrack smart system,hot & cold compress,saline solution,tena,tena classic,dry comfort extra,brief youth,promise pad,sur-fit natura drainable pouch,adhesive foam bandages,adhesi ve bandages,non adherent pads,nonadherent,little BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 228 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value ones active life pouch,stomahesi ve sterile wafer,allkare adhesive remover wipe,active life drainable pouch,active life closed-end pouch,visi-flow stoma cone,stomahesiv e protective,surfit night drainage tubing,sur-fit drainage container,allkare protect barrier wipe,flexi-trak anchoring device,moist towelettes,freesty le unistik 2,freestyle system,shrink band,bottletop dispenser adapter,unguator lid,syringe filter, millex-gp,plastic white hdpe bottle,amber round glass bottle,lipo cream base,sur-fit natura stomahesive,acti ve life,fitted BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 229 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value brief,active life urostomy pouch,sur-fit autolock stomahesive,surfit autolock drain pouch,sur-fit autolock durahesive,active life convex,pediskin adherent #2,pedi-pre tape spray,pedipre,active life pouch,duolock curved tail closure,sur-fit-act life-tail closures,sur-fit tail closures,ostomy appliance belt,little ones sur-fit ped belt,hydro armor ag blister care,active life stoma cap,selfgrip,transport chair,setopress high compression,kalt ostat fortex,disinfecting unit,compact disinfecting unit,fashion case,aquacel,len s cup,duoderm BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 230 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value hydroactive,accu sure,duoderm,str ong strips,sur-fit autolock pouch,optipore,s af-gel,nitetime,ez ject lancets,major comfort,feminine cleansing cloths,lice removal comb,combiderm acd,duoderm cgf,personal washcloths,minic omp compressor nebulizer,compmi st compressor nebulizer,earloop masks,interdental stimulators,aeroc hamber plus,aerochambe r,snug denture cushions,thermod ent,sur-fit natura convex inserts,topcare clickfine,visi-flow irrigator stoma cone,sur-fit natura little ones,sur-fit natura urostomy pouch,sur-fit natura irrig sleeve,sur-fit nat irrig BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 231 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value faceplate,hugo rolling walker,bullseye mini safety lancets,sur-fit natura durahesive,color lancets,durahesiv e moldable convex,easy twist & cap lancets,flexiseal,blood glucose monitor,surechek glucose control,sure edge blood glucose meter,sure edge glucose control soln,alternate site lancing device,aqua lance lancing device,sms glucose control,safetylet,safety seal lancets,needles,s ur-fit natura closed-end pch,renew advanced lancing system,eakin cohesive seals,carboflex,a ctive life onepiece,duoderm signal,versiva,sur BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 232 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value epress,sur-fit natura visi-flow set,unnaflex,unna-flex plus,topcare ultra comfort,renew advanced microlancets,amigo insulin pump,glucopro,fl exiflo,hugo folding walker,hugo cane,hugo transport,smart sense lancets,ezject lancets,airgo rolling walker,topcare universal1 thin lancet,ultra thin plus lancets,ultra thin plus,smart sense,contact lens conditioning,whe elchair,acapella,f eminine bulb syringe,feminine folding syringe,vaporizer cleaning tablets,vaporizer inhalant,fountain syringe,feminine compact travel syrnge,attachme nt set,enema BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 233 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value syringe,rectal syringe,ultratrak pro,crutch accessory kit,vocalpoint glucose control,vocal point glucose control,autolet impression,one step at a time,sur-fit natura pouch,crutch,surfit autolock inserts,shield,surfit autolock,feminine combination syringe,forehead thermometer,bab y thermometer,oral thermometer,cerv ical collar,sur-fit natura flange cap,o-calette,sur-fit natura mini-pouch,cool mist,super pad,super underpad,regular pad,nutriport balloon,curasilk,e xcilon,add-a-foley cath-pre-fill syrn,kangaroo nasogastric feed tube,vistec,t.e.d. anti-embolism BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 234 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value stocking,curity runarounds,curity run arounds,kangaro o gravity set,curity sleep pants,curity o-b sponges,curity lumbar puncture tray,monoject safety syr tip cap,kerlix burn pack,simplicity adult flat fold xl,curity detectable lap,dover catheter,polyskin ii,kendall,dover red rubber robibson cath,rondic,kerlix amd,wings,dover bulb syringe,handicare ,versalon washcloth,curity washcloths,curity bedside drainage bag,curity urine meter,tenderol,de rmacea,foley catheter tray,monoflo,curity bedsidemono-flo drange,simplicity adult poly,curity ureteral drain BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 235 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value set,curity premium catheter tray,add-a-foley cath-mono-flo drng,dover foley catheter,curity strmlin cath wmono-flo,wings choice plus adult briefs,wings choice adult brief,wings classic adult briefs,wings classic,wings choice plus youth briefs,argyle trocar,wings classic youth briefs,unigard,t.e. d. sequnt compress device,h-tron plus,copa hydrophilic foam,h-tron pluspiston rod,htronplus adapter,curity surgical,curity spng counter rack-scale,clean catch-soap towelettes,clean catch-benzalkon towelets,kenline add-a-foley tray 30cc,curity thoracentesisBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 236 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value cath tray,monoject pharmacy tray,curity spng counter bag strips,aquaflo,flex -wrap,curity thoracentesis trays,monoject,w ebril ii,dermacea stretch,dermacea nonwoven,xeroform,v aseline petrolatum gauze,pre-moist pads,replacemen t pads,tensor,foley catheter,curity irrigation tray,heavy drainage dressing steril,robinson clear vinyl catheter,kenguar d,specipan collection unit,urinary leg medium bag,tenderskin,cu rity ureth cath closed systm,add-a-foley tray,microlife peak flow,webril,lisco,c urity ureth cath BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 237 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value open system,incontrol bp monitor,wetpruf,kerlix amd bandage,curity ultramer irrg 3way cath,curity bedside drainage set,sharps a gator,wings underpad,argyle connecting tubes,curity universal w-o drainage,monoje ct luer adapter,precision 200 catheter tray,monoject blood collection,curity cleaners medium,dressing change-pov-iod tray,conform,curit y ultramer 2-way catheter,sure care protective underwear,sure care protective undergmnt,kenda ll paper tape,curity cleaners large,curity foley catheter kit,maxicare,inco ntrol pen needle,lea's BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 238 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value shield,monojector lancet device,glucolab,g lucoleader,windm ill trainer,biobrane,u lticare syringe,biobrane gloves,careone,in control lancing device,advanced lancing device,incontrol super thin lancets,incontrol ultra thin lancets,kinney brand lancets,neuropen monofilaments,bu rn matrix,wound matrix,curasol hydrogel,curasol gel,spectragel,ultr aheal,soothing nonstick,polywic,ken dall cloth,maxicare underpads,wings supreme,curafil,w ings maxima,wings fluff and polymer,curistrip,sta-put,first aid hurt-free wrap,band-aid flexible BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 239 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value fabric,curity 8000 urine meter,curity ultramer catheter,sharpsaf ety container,kendall container,rcra hazardous waste,dover coated latex foley,dover urine leg bag,kangaroo 1000ml pump set,curity iodoform,telfa amd,kangaroo epump set,tenderwrap unna boot,curity ultra fits,kerlix lite,disgard sharps pad,diapers-disppolyethylene back,super absorbent underwear,ultrathin underwear,polyrayon,sani-zone ostomy deodorant,brief, medium,denture cleanser,coolmag ic,triple helix collagen,foam dressing,gelpad, woundgard gauze,covrsite,pri BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 240 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value mapore,primapor e iv,opsite adhesive dressing,flexigel, viscopaste pb7,transigel,micr osponge,spray pump,sensitive eyes drops,saline solution, unpreserved,allev yn cavity dressing,allevyn tracheostomy dressing,unlabele d refill bottle 240ml,covrsite plus,intrasite,telfa clear,super denture adhesive,presenc e,quiksept,simplicity liner,disinfecting solution,lens lubricant,hypoclear,monoject luer lock tb syringe,dover advantage drainage,wetting & soaking solution,monoject tb syringe,concentra ted cleaner,dover premium,renu weekly cleaner,dover BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 241 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value pediatric urine,dover advantage,surec are,enema bag,sharps-agator,touchtrol,curity maternity pad,davol complete foley kit,davol urinary drainage bag,davol foley cath insert tray,davol universal catheter tray,bardia urinary drainage bag,davol clsd sys foley cath tray,davol irrigation tray,davol irrigation syringe,irrigation tray,basic irrigation tray,vigilon wound dressing,urethral catheter tray,universal foley catheter tray,bardex urethral catheter tray,infection control tray,bardex lubricath foley BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 242 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value tray,stoma urine bag,extra security pouch,scanpor tape,opsite flexifix,davol urethral catheter tray,davol silicone foley catheter,bardex closed system cath tray,skinbond cement,urikleen,remove wipes,remove liquid,uni-solve adhesive remover,profore, opsite flexigrid dressing,hypafix, no sting skin prep,opsite postop,stayfree surefit,stayfree maxipad,stayfree ultra thin,drain,bardic adaptertubing,tena serenity,cunningh am incontinence clamp,catheter,ca refree panty shield,serenity ultra plus,dispoza-bag leg bag large,dispoz-abag leg bag medium,dispoza-bag leg bag BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 243 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value small,urethral catheter,toomey syringe,female intermittent catheter,male external catheter,deluxe fabric leg straps,catheter strap holder,bardic uro sheath vinyl,leg bag holder,uro sheath disposable bulk,bard center entry close system,latex leg straps,latex extension tubing,two-sided adhesive strips,bardex silicone foley catheter,leg bag straps,infection control bag,adhesive remover wipes,protective barrier film,cleancath,rubber utility catheter,micropor e first aid paper,micropore first aid skintone,micropor e first aid plastic,micropore BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 244 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value first aid waterproof,micro pore first aid cloth,micropore air wrming fltr mask,micropore pollen filter mask,micropore germ filter mask,reston,dure x avanti bare,aerochambe r z-stat plus,aerotrach plus,aeroeclipse ii,aerogear asthma action kit,aerochamber mv,aerochamber mini,relion confirm,trustex condom,relion prime,trustexria,trustex latex condom,trustex,f antasy,drain pouch-filterflange,drainable pouch w-filtrflange,urostomy pouch with flange,karaya seal closed stoma pouch,drainable mini-pouch wflange,cpl drainable pouch,drainable BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 245 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value pouch,stoma combo cone-tube irrg kit,stoma cone w-connector unit,stoma combo cone,tube irrg drn,medical adhesive,adhesiv e remover,ostomy belt,urostomy drain tube adapter,hollihesiv e skin barrier,pouchkins urostomy pouch,pouchkins drainable pouch,pouchkins drain tube,drainable pouch with flange,skin barrier w-floating flange,pouchkins pouch,pouchkins pediatric belt,stoma irrigator drain wflange,premium drainable pouch,pouchkins skin barrier,convex syn barr w-float flange,karaya drainable ostomy pouch,karaya 5 drainable BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 246 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value pouch,stoma cap w-deodor fltrflange,stoma cap w/deodor fltr/flange,centerp ointlock closed pouch,premier drainable pouch,centerpoin tlock flextend skin,walker wheels,personal confidence underwear,premi er lock n roll,premier urostomy pouch,camo bandages,folding walker,adhesivebarrier remover wipes,filter replacement,m9cl eanerdecrystallizer,sto ma lubricant,odor eliminator,karaya paste tube,skin gel protective dressing,karaya,a dapt stoma powder,adapt barrier ring,softflex skin barrier,loop ostomy bridge, sterile,premium skin barrier,steristrip wound BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 247 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value closure syst,tegaderm hydrocolloid,soft cloth,extra absorbent shield,medipore plus pad,medipore dress-it,bladder control,medipore, tegaderm i.v.,tegaderm i.v. advanced,medipo re h,steristrip,microfoam,bl enderm,medigrip, carrasyn hydrogel wound,evencare g3,medfix ez,exuderm satin,filter security closed pouch,contour i,lo-profile urostomy pouch,stoma cap w-micropore adhesive,procha mber,optionhome ,optichamber diamond,innospir e essence,innospir e elegance,sidestre am nebulizer,sidestre am mask,sami BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 248 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value the seal,litetouch,sa mi the seal mask,sami the seal filter,sidestream pediatric,mini elite filter replacement,mini plus nebulizer,optihale r,optichamber,pe diatric mask,sidestream plus,inspiration elite filter,micro plus,innospire replacement filter,asthmapack children's,asthma pack iii,asthmapack ii,asthmapack i,assess,foot and shoe padding,misterne b pediatric compressor,pers onal best,asthmament or,asthma check,threshold pep,threshold imt,inspiration elite,minielite,micr o elite replacement filter,misterneb nebulizer,micro BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 249 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value elite,pflex trainer,tegaderm hp,flexible foam bandage,quake,p rimeaire,wild hot strips,inspiration,l iteaire,misterneb compressor,tega derm hydrocolloid thin,tegasorb thin,tegaderm absorbent,napkin hospital tabbed,tegaderm ag mesh,incare,adva nce plus intermittent,twopiece stoma caps,closed-end pouch,premier closed minipouch,adapt,ada pt convex barrier,adapt barrier,adapt paste,premier skn barr w-float flang,premier closed pouch,premier colostomyileostomy,premier urostomy,onepiece drainable pouch,mini drainable pouch,platinum urostomy BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 250 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value pouch,urostomy pouch,microderm ,mini urostomy pouch,one-piece urostomy pouch,night drain adapter,ilesorb,drainable pouch closure,microskin applicator,cymed seal,adhesive barriers,microskin barrier,adhesive barrier,system pouch,super strip bandages,microd erm plus,new image flextend,new image flexwear,new image skin barrierflange,new image skin barrier,fecal collector,retracte d penis pouch,extended male catheter,premier urostomy pouch/flange,eve ryday male catheter,drainabl e pouch clamp,flextend skin barrier,fecal collector, BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 251 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value drainable,vented urinary leg bag system,bedside drainage collection,female urinary pouch,vertical drain-tube attach dev,suction tube attachment device,drain-tube sterile clamp,horz drain-tube attach device,feeding tube attachment device,replaceme nt neckband,wound drainage collector,universa l catheter access port,bag-tubing system,bag-strap system,vent urin leg bag sys,combo pk,new image,new image urostomy,new image urostomy pouch,new image drainable minipouch,new image drainable pouch,new image closed minipouch,new image drainable kit,transparent i.v. BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 252 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value site dressing,new image colostomyileo kit,new image kit,adjustable lancing device,ostomy protective powder,reliamed safety seal lancets,transpare nt thin film dressing,new image urostomy kit,reliamed mini lancing device,protective barrier wipes,cervical soft collar,new image irrigation sleeve,pipette 120ml catheter tip,pipette 90ml catheter tip,plastic adapter for busher,pipette 30ml catheter tip,asepto bulb syringe glass tip,asepto bulb syringe cath tip,pipette 45ml catheter tip,syringe,tuberc ulin syringeneedle,quince spinal needle,yale BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 253 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value spinal needle,tempaway thermometer sheath,cornwall accessories & parts,cornwall metal pipeting holder,allergist syringe with needle,allergist tray,allergist syringe,tuberculin syringe,yale cleaner,allergist syringe tray,syringe bulk,bulk syringe,needle,ca nnula,interlink syringe,lever lock cannula,twinpak dual cannula,interlink syringe wcannula,specialty use needles,regular bevel needles,ultima,sh ort bevel needles,tampertuf,thin wall needles,cornwall syringe tip connector,nokor needle,nokor admix needle,simplecho BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 254 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value ice,yale needles,simplech oice quick,precisiongli de,md turbo,blunt needle,safety-lok safety syringe,safety-lok safety syringes,sharps collector,medsav er,sharps container,syringe storage bin,eclipse needle,integra syringe,glaspak,i ntegra needle,one-piece sharps collectors,glucos ource,instant ear thermometer,brite sight thermometer,hyp otherm thermometer,exel insulin syringe,digital therm probe cover,dressing,ex el hypodermic needle,exel mti drawing needle,psv set,children's sudacare,sudaca re,bed pad,ace wrist brace with BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 255 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value splint,exel tb with needle,ace lumbar support,bd genie lancet,exel tuberculin syringe,exel allergy syringe,whitacre spinal needle,pudendal & parasympathetic, yale needle regular bevel,protection plus liner,dry time diaper,yale needle huber bevel,intravenous ,arterial & blood,special needle,peg elastic bandage,yale needle,everyday long pantiliners,lubrica ting drops,yale needle short bevel,rigid gas permeable cleaner,rgp wetting and soaking,economy underpad,lubricat ing & rewetting,ultra soft,molicare BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 256 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value classic brief,iv catheter,exel huber,exel huber needle,plastic adapter kit for busher,iamin,osm ocyte,yale syringe,reston2,cornwall syringes luer-lok tip,yale glass tb syringe,rosenthal, osgood,security bead needle, local,klatskin,ani mas 2020,vacutainer collection set,inset infusion set,insulin pump,cartridge,in syte autoguard,flexible foam strips,inset 30 tubing,infusion set,insyte iv catheter,infusion pump,angiocath iv catheter,angiocat h,contact detach infusion set,saf-tintima iv catheter,nexiva,s af-tintima,introsyte autoguard,qsyte,inset 30 infusion set,saf-t BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 257 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value e-z collection set,e-z set winged infusion set,saf-t e-z set,myelogram tray,precise,statlet,ibgstar,micro,relion micro,sheer strips,clear strips,plastic strips,ultilet safety,ultilet insulin syringe,beltless undergarments,p ersonal confidence pads,publix lancet,accu-chek aviva plus,suresite matrix,accu-chek fastclix,accutrend glucose,ultilet basic,accutrend cholesterol,perso nal confidence briefs,accu-chek compact blue control,overnight brief,coaguchek xs pro,accutrend plus,personal confidence underpad,silvasor b,pressure activated lancets,evencare BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 258 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value g2,accu-chek smartview,tender wet active cavity,onetouch ping,evencare,ex uderm odorshield,cartrid ge pump,cartridge stamped,silvasor b cavity,safetyglide needle,safetyglid e syringe,safetyglid e insulin syringe,heavy duty fabric strips,eclipse syringe,syringeneedle,eclipse syringeneedle,eclipse luer-lok syringe,safety syringeneedle,syringe tip cap,safetyglide tb syringe,personal confidence liners,safetyglide allergy,safetyglid e allergy syringe,luer-lok syringeneedle,natural care bandages,clear waterproof BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 259 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value strips,basics for kids,syringe-luer tip cap,scar care,syringeprecisionglide needle,tb syringe,syringe catheter tip,safety-lok syringes,lancet device,bd ultrafine ii,safeclip,magni-guide magnifier,bd ultra-fine pen needle,bd ultrafine,luerslip syringe,autoshiel d pen needle,baby basics,slip-on undergarments,a uto injector,safety-lok collection set,microtainer lancets,bd microtainer lancets,luer-lok access device,vacutainer blood transfer,paradigm link blood glucose,autoshiel d duo pen needle,effervesce nt denture cleansr,effervesc BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 260 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value ent denture,re-nu fresh,boston simplus solution,wetting solution for hard lens,aquacel foam,home care underpads,confor m stretch bandage,renu rewetting drops,bio true,boston advance cleaner,renu multiplus,sensitiv e eyes daily cleaner,takeoff,premier skn barr w/float flang,coets,e.p.t,h eat comfort,cloth first aid tape,foam sports tape,3m non-stick pads,moist wipes,dermiclear, kling bandage,dermilit e ii hypoallergenic,dermic el hypo-allergenic tape,dermilite-ii paper tape,cut n crush,puralin,sur gilance lancets,antiembolism stockings,e.p.t BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 261 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value digital,truform compression stocking,knee stabilizer,elbow strap,elbow support,wrist support,tennis elbow brace,multipurpose ice & heat wrap,backshoulder ice & heat wrap,deluxe laced ankle brace,ankle support,ace ankle support,cold pack back pad,cold wrap,ankle stabilizer,flushabl e moist wipes,warm steam vaporizer,hand support,maxi regular,maxi super,maxi deodorant,deluxe back stabilizer,back stabilizer,contour ed back support,deluxe ankle brace,viasorb,xer oflo gauze dressing,ultec,bli sterfilm,expandov er,q-tips wood BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 262 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value stick applicator,interso rb,kangaroo enteral-feed-irrig kt,kangaroo deluxe pump set,precision xtra,kangaroo 1000ml gravity bag,kangaroo pump set,kangaroo 500ml pump set,kangaroo pump extension set,kangaroo ysite extension set,kangaroo 1200ml rigid containr,kangaro o rigid container,kangar oo 1200ml deluxe pump st,kangaroo proximal spike pmp st,kangaroo screw cap pump set,kangaroo 1600ml deluxe pump st,kangaroo plyurethane feed tube,texas catheter,kangaro o 100ml rigid burette,early pregnancy test,two-sided BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 263 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value adhesive strap,uridrain,elastic foam strap,catheter with strap,test n'go,vaseline constant care,rob-nel pvc catheter,terumo insulin syringe,terumo surguard2,premie r adult brief,safety syringe with shield,monoject safety syringe,syringe without needle,monoject syringe pharmacy tray,monoject smartip cannula,easymax l,monolet thin lancets,monolet lancets,easymax v speaking,easyma x speaking,easyma x v,easymax v2,glove box,monoject magellan,easyma x ng,easymax 15,sharps container accessory,easypl BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 264 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value us r13n,easyplus v,magellan insulin safety syrng,magellan insulin syringe,safe klean,cleo 90 infusion set,oral medication syringe,3m paper pre-cut tape strips,finger grip extender,active strips,magellan tuberculin syringe,waterpro of adhesive,monoje ct megellan tb syringe,clear first aid tape,kangaroo pet carrying case,extender caps,kangaroo pet charging cord,kangaroo pet pump frame,one-step blood pressure monitr,boston rewetting drops,boston one step,precision q-id,precision link,precision softact,starter kit,precision,micr ospacer,microcha BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 265 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value mber,dental floss unwaxed,terumo surguard,terumo allergy syringe,thinpro insulin syringe,dover universal,mercury klean kit,terumo syringe,terumo hypodermic needlesyrin,ultratrak ultimate,advocate duo,advocate control solution,ultratrak, ultralance,advoca te redicode+,advocate redi-code+ ctrl soln,advocate lancets,advocate redi-code duo,provent sr,provent hr,advocate blood glucose monitor,advocate redicode,advocate syringes,advance d healing bandage,advanc ed healing pad,medical id for necklace,victory,t egaderm + pad,embrace BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 266 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value glucose control soln,medical id for bracelet,vacustim black,easy touch fliplock syringes,riteflo,ea sy touch fliplock syringe,advocate rapidsafe,medisense control,easy touch fliplock needles,ultratlc lancets,easy touch fliplock needle,ultraflex,restore calcium alginate,medisen se glucose ketone,restore,re store hydrogel,medisen se glucose ketone contr,restore hydrogel gauze,freestyle insulinx,precision glucose control,optium,bu rns-scaldsabrasions,skin closure,blister care,restore odorabsorbent,restore hydrocolloid BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 267 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value dressing,restore ex thin hydrocolloid,profit ,medisense,medi sense thin lancets,quick response,cinis preemie halo,sterilance tl,restore contact layer silver,restore contact layer,water shield bandages,restore trio,fora d40,restore duo,plastic bandages,restore foam heel dressing,foam bandages,agama trix control,wavesens e control solution,keynote, nova safety lancets,keynote pro,wavesense presto,jazz wireless 2,liberty blood glucose meter,presto pro,wavesense amp,ear popper,vgo 20,vgo 30,vgo 40,liberty control solution,bionime BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 268 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value rightest gm300 system,rightest control solution,rightest gd500,rightest gm100 system,rightest gm550 system,rightest gl300 lancets,ge100 blood glucose system,ge100 control solution normal,nova sureflex,nova max blood glucose meter,nova max glucose control soln,novamax plus gluket,conception,s martest eject,smartest protege,smartest pronto,smartest persona,smartest smart code,smartest talking,glucocom lancets,blood glucose meter,glucocom blood glucose,glucoco m,glucocom control solution,glucose BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 269 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value control solution,glucoco m autolink,glucose control,bloodglucose control,rightest gm300 system,monoject control syringe,ankle supportelastic,monoject tuberculin safety syr,elbow supportelastic,monoject insulin safety syrng,wrist splint support,neoprene wrist splint,sterile bandages,droppe r,allergist tray syrdetach ndl,monoject tuberculin syringe,enlite,pre vail pads,monoject allergy trayneedle,super moleskin,allergist tray syr-perm needle,filter aspirator needle,transfer needle,new generation,bone marrow aspir BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 270 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value needle,lifeshield blunt cannula,orsini insulin syringe,easy touch sheathlock syringe,easy touch unislip,neoprene knee support,vios aerosol delivery system,neoprene ankle support,filter connector,breath e right,pulmoneb lt compressor nebul,droplet lancing device,gdrive,sev en system sensor,seven plus,diabetic socks,invacare lancets,smart caresens n,solus v2 lancets,solus v2,liberty monitor,solus v2 control solution,solus v2 lancing device,liberty lev 1 glucose control,liberty lev 2 glucose control,sidekick,tr uetest glucose control,truecontro BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 271 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value l,needle-pro edge,truetrack,pr estige smart system,prestige,p restige meter,prestige value pack,personnel protection,cool blood glucose meter,p2 hirisk,multimix,designer,wat ergard,unistik 3 neonatal,unistik 3 extra,unistik czt,unistik 3 comfort,chemo plus,chemosafety prep admin,g4,chemolinen hamper stand,chemowast e hamper stand,chemowast e bags,chemolinen waste bags,control,easy gluco,easygluco meter starter kit,all flow 7000,spill proof prep mat,acura starter kit,acura control solution normal,u.v. protection bags,infinity BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 272 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value control solution,infinity,ch emosafety container,multilancet,safelock bags,easygluco plus,acura plus,easygluco plus control normal,acura control solution,acura meter kit,acura control solution low,elasto-gel circle dressing,autolet plus,toe aid dressing,compact ultrasonic nebulizer,compac t compressor nebulizer,elastogel hot & cold wrap,easy touch hypodermic needle,chemoplu s,co monitor replacement t,co monitor,splash shield short,chemoplus powder free,splash shield flex,disposable paper mouthpiece,miniwright peak flow meter,oncology BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 273 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value plus,in-check oral,in-check nasal with mask,topcare universal1 lancet,pro star powder free,easy touch luer lock syringe,airzone & miniwright afs,incheck dial,p2 safety plus powder free,pediatric mouthpieces,p2 hi-risk powder free,pedi-small mouth adaptor,one flow spirometer,one flow fvc,airzone peak flow meter,p2 safety plus,one flow mouthpiece,silico ne mask,filtered mouthpiece attachment,dustmist respirator mask,breathrite,n ose clip,rubber mouthpiece,all flow 1000,all flow 2000,all flow 3000 pft,all flow 3000 kit,all flow 4000,all flow 5000,all flow 6000,insertion BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 274 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value tray with bzk,microhesive stoma paste,chemoplus dispensing pin,curity foley 2way ped cath,thalaset,fole y cath silicone retn,relion pen needles,clever choice control solution,tubeguar d,insuflon,clever choice hd glucose syst,neria,clever chek lancets,clever chek blood glucose syst,clever choice blood gluc sys,pocket chamber,pediatri c panda mask,panda mask,expiratory,c lever choice pro,femcap,cleve r choice,clever chek,pharmacist choice,clever choice micro,clever choice talk,pillow mask,splash shield full,pillow mask for BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 275 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value children,eclipse,e clipse control solution,envision, fifty50 reservoir,thinset,fi fty50 safety seal lancets,freestyle precision,freestyl e freedom lite,iport,smartest,bab y nebulizer,smartes t lancet,lc star,pari lc plus nebulizer,sinustar ,lc sprint nebulizer,element plus control solution,glucolab control,lc d nebulizer set,lc plus,smartdiabete s xpres,element control solution,xpres,sm artdiabetes vantage,element plus,evolution blood glucose meter,element blood glucose meter,evolution control solution,fora v10,easy touch insulin syringe,fora d15,fora d20,fora g90,fora v22,fora BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 276 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value g30a,fora g20,fora v20,easy touch lancing device,fora d10,easy touch control solution,freestyle lite meter,1st choice lancets,freestyle freedom,freestyle control solution,freestyle lancets,omnipod,f reestyle navigator,freestyl e flash system,freestyle sidekick ii,fora lancing device,foracare lancets,prodigy pocket pro,prodigy autocode pro,alcohwipe,prodigy pocket,alcohglove,prodigy voice,prodigy voice pro,novopen echo,prodigy lancets,prodigy twist top lancet,prodigy,pr odigy duo,prodigy control BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 277 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value solution,prodigy preferred,prodigy insulin syringe,droplet lancets,easy touch glucose monitor,prodigy lancing device,prodigy pen needle,ultracomf ort,vortex,bubble s the fish ii,mask vortex,baby conversion pack 2,mask set with y-piece,filters replacement,bab y conversion pack 1,altera nebulizer,trek s portable pwr kit,trek s combo pack,vortex ladybug mask,vortex frog mask,wing tip tubing,pari lc sprint sinus,pari sinus aerosol system,filter pad,filter, valve set for ll & lc,chemo spill kit,prodigy eject,proneb ultra,smartmask kids,proneb ultra ii,eflow scf,eflow BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 278 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value scf nebulizer handset,eflow scf aerosol head,prodigy mini-mist,prodigy count-adose,easy pro plus,proneb ultra ii deluxe,colostomy barium enema kit,flexi-seal fecal,lancing system,rate flow regulator iv set,aerobika,ultilance,toothbrush precision head,combine abd,underwear for men,unistrip,shee t protector,prevail purseready,easy step,easy check control solution,easy plus,easy plus ii,quintet,blood glucose control,quintet ac,choicedm clarus control soln,choicedm clarus,monaghan z stat,aerochamber plus z stat,nasoneb BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 279 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value nasal nebulizer,aeroecli pse,opti-zyme enzymatic cleaner,flexible bandages,accuchek compact plus control,toothpast e,toothbrush adult deluxe,onetouch verio sync,sootheneb mesh nebulizer,cotton squares,cosmetic balls,cosmetic puffs,onetouch verio flex,prevail boxers,prevail full coverage undrwear,flexible bandage,nufit underwear,prevai l simply stretch fit,per-fit brief,breezers,val ue buy,fora lancets,nu-fit brief,cosmetic squares,prevail super plus,prevail protective underwear,prevai l adjustable,prevail extra underwear,prevai BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 280 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value l classic fit underwear,prevai l bariatric,ben-efit,prevail breezers,nufit brief,per-fit underwear,perfit brief,prevail male guard,prevail guards for men,prevail extra bladder,prevail extra plus bladder,prevail panty liner,prevail ultra bladder,prevail ultra plus,prevail pm,propylene glycol,easy touch lancets,easy check,easy click,droplet pen needle,waterproo f strong strips,reveal ovulation test,reveal pregnancy test,mini lancing device,reveal get pregnant quick,reveal ovulation predictor,reveal blood glucose meter,maxicomfort,mini ultra-thin ii,inject BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 281 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value ease lancets,blood lancets,mesh pants,snap pants,affirm underwear,affirm pads,pant liner large plus,procare washcloths,ameri can star washcloths,perso nal cloths,cuties wash cloths,cuties baby wipes,prevail bladder control,prevail premium washcloths,preva il wet wipes,up & up pantiliners,aerove nt plus,agiegrx,hydrophor gauze,geridyne,erase raspouri,erase,karay a gum,grx foam dressing,island gard-grx,grx hydrogel gauze,hydrocollgrx,calalgingrx,calalgin-grx rope,foracare gdh,bloodglucose BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 282 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value meter,freestyle precision neo meter,linktemp,iport advance,catheter tip cap,winged,dentu re,medicool's diasox,toe straightener,laird tip,freedom t-tap leg bag kit,freedom leg bag,tube & connector kit,freedom twist port leg bag kit,colostotip,colo stotip w-quick disconnect,femal e specimen catheter,selfcath,shut off for tubing,tubing for irrigator,insertion tube catheter,quick disconnectconnector,travel case,shield for insertion tube,lubriwipe,compact irrigator,colostokit irrigator,hospital pack irrigator,mounting ring,elastic belt,enema bag BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 283 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value with catheter,shut off for 5000 enema bag,ultrafresh,sleeve closure clamp,irrigation syringe,bioguard conforming,active cath,urological catheter,step 3moisture barrier,step 1incontinent cleanser,step 2moisture cream,3 step skin care,female self catheter,day & night brief,baby conversion kit,vortex vhc ladybug mask,vortex vhc frog mask,elta dermal,erapid nebulizer,mask set,erapid nebulizer handset,acticoat site,on call lancing device,on call lancet,on call plus lancet,neurostimu lation electrodes,tens 504,tens 502,on call vivid control,mesalt,ten BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 284 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value dra mepilex border,on call plus control,on call plus lancing device,seal tight,band-aid activ flex,hypoallergenic bandages,dental adhesive,uro-san plus,jobst antiembolism stocking,freedom cath,fabric bandage,comfort leg bag straps,callus pads,freedom drainage bag,gizmo,contin ent urinary catheter,clear advantage,lamb's wool,deluxe leg bag straps,plastic connector,urosan leg bag,dermaguard,cone tip,colostopads,fr eedom pak seven,e-z hold,gizmo foam straps,doublehesive,mini-drain open end pouch,economy pouch,touch ii,response BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 285 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value ii,piston ii,attends light insert,attends booster,attends guards,tissuepak, attends,attends disposable underpads,attend s insert,attends undergarments,at tends underwear,poly hub needle,varnal,zar osen,dee fog,finger splints,sure comfort lancets,sure comfort lancing pen,smoker's polident,polident,j etco-spray cannula,gallon jug with pump,jobst ultrasheer,actis,ctub,super wernet's denture,dentucreme,fora tn'g voice,dentugel,super poligrip,sensodyne,a cticoat flex 7,mixing container with lid,bard irrigation tray,3m cold-hot BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 286 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value pack,acticoat moisture control,capri bladder control pads,nail nippers,nail clip,toenail clip,polyfin,tugab oos diapers,paradigm infusion,sofserter,paradigm insulin pump pathway,tugaboo s overnights,polyfin qr,sof-set,sof-set micro,quick release soft teflon,guardian rt system,guardian realtime,paradigm realtime,guardian rt starter kit,disposable probe covers,guardian transmitter tape,sofsensor,1.5 volt batteries #357,minimed reservoir,replace ment pediatric monitor,paradigm silhouette,silserter,quick-set BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 287 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value paradigm,minime d,non-slip underpads,delux e underpads,guardi an test plug,paradigm,to enail nipper,silhouette, revel programmable pump,minilink real-time transmitter,paradi gm insulin pump,guardian rt charger,paradigm remote control,medtronic remote control,minimed infusion,mio infusion set,senserter,sure-t paradigm,suret,instant heat therapy,surechoic e,soft touch pill reminder,cotton gloves,self grip,ultra fine cut n crush,instant heat,hot & cold therapy brace,linen fresh,over nites,visine for contacts,bengay moist heat BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 288 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value therapy,cushion insole,ezo,sheer plastic strip,cotton, sterile,kid pants,fabric strip extra large,disposable razor,pro sports tape,ice cap,panty liners,avogel,wat er bottle-fountain syringe,foam insole,clear spot bandages,dental travel pack,carefree pantiliners,tena underwear,tena protective underwear,rewett ing,finger sleeves,back & neck cold pad,multi-use cold pad,panty shields,bulkee ii,briefs for men & women,flexible fabric bandage,urostom y multichamber,urostom y multi-chamber pouch,urostomy micropouch,assura easiclose,easiclo BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 289 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value se wide outlet,supreme,s ensura easiclose wide outlet,sensura flex ostomy base plate,sensura click ostomy pouch,assura,col oplast paste strip,assura ac,airs pediatric aerosol mask,sure choice pantiliners,sensiti ve baby wipes,bladder control pads for women,sensura ostomy base plate,sensura flex ostomy pouch,overnites,a ssura 2pc drainable,assura flange,assura pouch,conveen coude intermtnt cath,conveen drip collector,assura pediatric pouch,comfeel purilon,assura standard wear,assura flange convex,assura wound manager,pouch BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 290 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value clamp,filtrodor pouch filter,assura 2pc irrigation sleeve,assura irrigation face plate,irrigation set,comfeel seasorb,assura ostomy belt,assura extra,assura twopiece uro minicap,assura light easiclose drain,biatain,uros tomy night bag,assura nonconvex drainable,colopla st barrier ring,flexiflo magnaport,magnaport,ostomy paste,flexiflo over-theguidewire,colopla st skin barrier,coloplast paste,comfeel film,comfeel ulcer care,comfeel plus pressure relief,comfeel plus contour,comfeel plus clear,comfeel BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 291 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value plus triangle,coloplast closed pouch,coloplast drainable pouch,flexiflo topfill enteral bag,flexiflo easyfeed 500,coloplast,flex iflo top-fill bag,flexiflo feeding tube,ultra fine lancets,o.a.d.,co mfeel plus,woun'dres,e nteralite infinity,flexiflo top-fill,embrace bag set,nasoenteric tube,embrace adapter,flexiflo toptainer,flexiflo feeding bag,one touch lancets,companio n pump,durag,flexiflo quantum,thermip aq,y-port connector,tranqui lity topliner pads,select kids briefs,select disposable briefs,select underpads,diaper BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 292 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value booster pad,select underwear,atn brief,breatherite,r elion blood pressure cuff,evacare pessary,women's advanced bp monitor,peakair,comp-air elite compressor syst,reusable nebulizer kit,air tube with air plugs,micro air,self-taking blood pressure,airs disposable nebulizer,airs pediatric disposable mask,airs adult aerosol mask,easivent,ac e aerosol cloud enhancer,embrac e pole clamp,continuous glucose sensor,ep brief,hot & cold pack,patrol,medilice,gravity feeding set,toothbrush, total,pill divider with pill BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 293 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value box,medicine dropper,medicine spoon,pill box,pill planner,quantum pump,lens lustre eyeglass cleaner,natura closed pouch,esteem closed pouch,stomahesi ve skin barrier,esteem synergy closed pouch,flexi-seal signal fms,natura stomahesive skn barrier,natura durahesive skin barrier,eakin cohesive slims,aquacel extra,gel toe protector,arch bandage,gel corn protectors,toe separators,gel toe spacers,comfortsmooth,truetrack blood glucose system,convatec night drainage tubing,flight ear plugs,visi-flow sleeve tail closures,allkare adhesive remover BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 294 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value wipes,flexi-seal fms,sur-fit natura adaptor,sur-fit natura lowpressure,sterile bandage roll,gentle adhesive bandages,sheer adhesive bandages,plastic adhesive bandages,convat ec night drain container,little ones skin barrier,little ones drainable pouch,little ones closed-end pouch,ultra-soft gloves,visi-flow irrigation sleeve,blister relief,sur-fit natura high output,visi-flow irrig starter set,little ones urostomy pouch,quick read,muppet strips,heat wraps,hypoallergenic bandage,needle free syringe kit c,tena stretch ultra,needle free BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 295 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value syringe kit a,needle free syringe kit b,tena pants,medi-jector vision,medi-jector needle-free syr a,medi-jector needle-free syr b,medi-jector needle-free syr c,tena classic plus,opsite,harmo nie,opsite flexigrid,skin closure strips,algisite,alle vyn cavity wound dress,dry comfort,uniflex,ga uze dressing,rewettin g drops,trudent,one step ovulation test,diabetic.com starter,life medical starter,gauze,dis posable brief,reservoir,ho me pregnancy test,cleaning solution,nonpreserved saline,oragrip,lad y's shaver plus lube strip,weekly pill planner,shave cream,blade BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 296 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value double edge,pill divider,tugaboos training pants,quiet please foam ear plugs,poison first aid kit,facial cleansing sponge,absorben t shield,underwear for women,underwea r menwomen,blood pressure cuff monitor,boxers for men,soft-tip thermometer,und erwear for men & women,push n pop pill reminder,am-pm locking pill reminder,medicin e dropper & spoon,clear bandage,pain free tape,flexible foam pad,callus cushions,plantar fasciitis arch sleeve,gel bunion cushion,cleaning & disinfecting lens,contact lens cases BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 297 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 ergocalciferol,cal ergocalciferol (vitamin d2) ciferol,drisdol,cal cidol ADD UM: QUANTITY 2 / Day 03/01/2016 montelukast sodium,singulair montelukast sodium ADD UM: QUANTITY 1 / Day 03/01/2016 montelukast sodium,singulair montelukast sodium ADD UM: QUANTITY 1 / Day 03/01/2016 calcitriol,rocaltrol calcitriol ADD UM: QUANTITY 4 / Day 03/01/2016 rocaltrol,calcitriol calcitriol ADD UM: QUANTITY 4 / Day 03/01/2016 tiazac,diltiazem er diltiazem hcl ADD UM: QUANTITY 1 / Day 03/01/2016 MEPHYTON phytonadione ADD UM: QUANTITY 5 / Day 03/01/2016 folic acid folic acid ADD UM: QUANTITY 1 / Day 03/01/2016 folic acid folic acid ADD UM: QUANTITY 1 / Day 03/01/2016 vitamin b6,pyridoxine hcl pyridoxine hcl ADD UM: QUANTITY 4 / Day 03/01/2016 vitamin b6,pyridoxine hcl pyridoxine hcl ADD UM: QUANTITY 2 / Day 03/01/2016 vitamin b6,pyridoxine hcl pyridoxine hcl ADD UM: QUANTITY 4 / Day 03/01/2016 vinateprenatal vitamins with m,maternity,mate calcium/ferrous rna,prenatal mtr fumarate/fa/selenium,prenat al vitamins/ferrous fumarate/folic acid/selenium ADD UM: QUANTITY 1 / Day 03/01/2016 prenatal,prenatal vitamins,p-d natal plus,p-d natal plus with folic acid,kpn ADD UM: QUANTITY 1 / Day prenatal vits wca,fe,fa(<1mg),prenatal vit calc,iron,folic acid (less than 1 mg) BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 298 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 dorzolamidetimolol,cosopt dorzolamide hcl/timolol maleate ADD UM: QUANTITY 0.333 / day 03/01/2016 pantoprazole sodium,protonix pantoprazole sodium ADD UM: QUANTITY 1 / Day 03/01/2016 plavix,clopidogrel clopidogrel bisulfate ADD UM: QUANTITY 1 / Day 03/01/2016 HUMALOG KWIKPEN U100,HUMALOG insulin lispro ADD UM: QUANTITY 0.667 / day 03/01/2016 fenofibrate,tricor fenofibrate nanocrystallized ADD UM: QUANTITY 1 / Day 03/01/2016 fenofibrate,tricor fenofibrate nanocrystallized ADD UM: QUANTITY 1 / Day 03/01/2016 HUMIRA adalimumab PEN,HUMIRA PEN CROHNUC-HS STARTER,HUMI RA PEN PSORIASISUVEITIS ADD UM: QUANTITY 0.22 / day 03/01/2016 HUMIRA adalimumab PEN,HUMIRA PEN CROHNUC-HS STARTER,HUMI RA PEN PSORIASISUVEITIS ADD UM: QUANTITY 0.15 / day 03/01/2016 JANUVIA sitagliptin phosphate ADD UM: QUANTITY 1 / Day 03/01/2016 JANUVIA sitagliptin phosphate ADD UM: QUANTITY 1 / Day 03/01/2016 JANUVIA sitagliptin phosphate ADD UM: QUANTITY 1 / Day 03/01/2016 ENBREL etanercept ADD UM: QUANTITY 0.14 / day 03/01/2016 celecoxib,celebre celecoxib x ADD UM: QUANTITY 1 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 299 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 PULMICORT FLEXHALER budesonide ADD UM: QUANTITY 0.034 / day 03/01/2016 PULMICORT FLEXHALER budesonide ADD UM: QUANTITY 0.034 / day 03/01/2016 TEKTURNA aliskiren hemifumarate ADD UM: QUANTITY 1 / Day 03/01/2016 TEKTURNA aliskiren hemifumarate ADD UM: QUANTITY 1 / Day 03/01/2016 JANUMET sitagliptin phosphate/metformin hcl ADD UM: QUANTITY 2 / Day 03/01/2016 JANUMET sitagliptin phosphate/metformin hcl ADD UM: QUANTITY 2 / Day 03/01/2016 golytely,peg-3350 peg 3350/sod sulf/sod and bicarbonate/sod electrolytes,gavily chloride/potassium chl te-g ADD UM: QUANTITY 10.959 / day 03/01/2016 ENBREL ADD UM: QUANTITY 0.16 / day 03/01/2016 colyte with flavor peg 3350/sod sulf/sod packets,peg bicarbonate/sod 3350chloride/potassium chl electrolyte,gavilyt e-c ADD UM: QUANTITY 10.959 / day 03/01/2016 SYMBICORT budesonide/formoterol fumarate ADD UM: QUANTITY 0.34 / day 03/01/2016 SYMBICORT budesonide/formoterol fumarate ADD UM: QUANTITY 0.34 / day 03/01/2016 LETAIRIS ambrisentan ADD UM: QUANTITY 1 / Day 03/01/2016 LETAIRIS ambrisentan ADD UM: QUANTITY 1 / Day 03/01/2016 LANTUS SOLOSTAR insulin glargine,human recombinant analog,insulin glargine, human recombinant analog ADD UM: QUANTITY 0.667 / day etanercept BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 300 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 cholestyramine cholestyramine/aspartame light,prevalite,que stran light ADD UM: QUANTITY 1 / Day 03/01/2016 triadvance,advan prenatal vitamin ced no.15/iron,carbonyl/folic natalcare,prenata acid/docusate sod l ad,mynatal advance,virtadvance,inatal advance ADD UM: QUANTITY 1 / Day 03/01/2016 natalcare,virt-vite prenatal vitamin gt,vinate no.16/iron,carbonyl/folic gt,trinatal gt acid/docusate sod ADD UM: QUANTITY 1 / Day 03/01/2016 trinatal prenatal vitamin ultra,vinate no.18/iron,carbonyl/folic ultra,inatal acid/docusate sod ultra,ultra natalcare,prenac are ADD UM: QUANTITY 1 / Day 03/01/2016 SPIRIVA RESPIMAT tiotropium bromide ADD UM: QUANTITY 0.133 / day 03/01/2016 pramipexole pramipexole di-hcl dihydrochloride,m irapex ADD UM: QUANTITY 1 / Day 03/01/2016 TAMIFLU ADD UM: QUANTITY 0.222 / day 03/01/2016 clopidogrel,plavix clopidogrel bisulfate ADD UM: QUANTITY 0.034 / day 03/01/2016 TEKTURNA HCT aliskiren hemifumarate/hydrochlorothi azide ADD UM: QUANTITY 1 / Day 03/01/2016 TEKTURNA HCT aliskiren hemifumarate/hydrochlorothi azide ADD UM: QUANTITY 1 / Day oseltamivir phosphate BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 301 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 TEKTURNA HCT aliskiren hemifumarate/hydrochlorothi azide ADD UM: QUANTITY 1 / Day 03/01/2016 TEKTURNA HCT aliskiren hemifumarate/hydrochlorothi azide ADD UM: QUANTITY 1 / Day 03/01/2016 HUMIRA adalimumab ADD UM: QUANTITY 0.08 / day 03/01/2016 hydrocodoneacetaminophen hydrocodone bitartrate/acetaminophen ADD UM: CUSTOM 40 PER 6 MONTHS 03/01/2016 hydrocodoneacetaminophen hydrocodone bitartrate/acetaminophen ADD UM: QUANTITY 0.111 / day 03/01/2016 prenatal rx prenatal vitamin 27 with 1,trinatal rx 1,se- calcium/ferrous natal one,vinate fumarate/folic acid one ADD UM: QUANTITY 1 / Day 03/01/2016 LEVEMIR insulin detemir ADD UM: QUANTITY 2 / Day 03/01/2016 LEVEMIR insulin detemir FLEXPEN,LEVE MIR FLEXTOUCH ADD UM: QUANTITY 0.667 / day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 302 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name 03/01/2016 humapen memoir,humapen luxura hd,adriaoncoline,triaminic flowing vapors,unisol 4 preservative free,ortho allflex,optifree,soaclens,sys tane contacts,clerz plus,opti-free replenish,irrigatio n administration set,schirmer tear test,opti-free express,secondar y set,spinal-22 wbupiv-epiephed,spinal anesthesia tray,ivex-rf filter set,evacuated container,ls plum primary setol,plumset primary setol,dial-a-flo iv extension set,dial-a-flo microdrip set,venoset secondary,soluse t with cair clamp,transfer set,decanting set,nonvented iv set 100 w- Generic Name Type of Change insulin admin. supplies,iv REMOVE UM: QUANTITY equipment,vaporizer,soft lens rinse-store solution,diaphragms, arcspring,diaphragm fitting set,arc-spring,gas permeable lens cleaner,hard lens clean-soak solution,wetting soln gas,hard and soft,soft lens adjunctive solutions,irrigation set,tear test,iv piggyback adminstration set,anesthesia tray,iv administration setfilter,container,empty,iv administration set,iv admin extension set-filter,iv admin extension set,iv administration setclamp,transfer sets,iv infusion pump accessory,blood administration set,iv administration set,nonvent,hyperalimentation equipment,miscellaneous medical supply,iv catheter kit,nerve stimulator device,blood administration equipment,iv infusion pump,in-line burette set,procedural tray,iv venipuncture needle set,iv catheter,dialysis (peritoneal) kits,blood collection set,vial,empty,feeder container with pump set,irrigation piercing pin Previous Value New Value 1.2 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 303 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name clamp,nitroglyceri n patient line,soluset 150x15 i.v. setsl,screw cap set,iv pump setivex-hp,blood ytype pump set,hema blood secondary pump,venoset piggyback,air filter,extension set with stopcock,anesthe sia extension set,syringe filter,cvp universal set,blood set,backcheck extension set,venoset with cair clamp,nonvented primary pg-bk wcair,blood set 78sl, y-type,blood set 82-sl,venoset t-type w-cair clamp,venoset secondary piggybk set,venoset sec piggyback,nutrimi x,abbott counting tray,cont epidural w-bupiv-epi,veniprep ii kit,veni- set,nv,calamine/zinc gelatin,inhaler, assist devices,inhaler, assist devices, accessories,facialbody sponge,n95 respirator, disposable,pen needle, diabetic,pen needle, diabetic, safety,syringe accessory,syr biopsyaspiration reusable,gloves,bloodglucose meter, disctype,blood glucose calibration control solution, normal,blood glucose calibration control solution, low,blood glucose calibration control solution, high,blood glucose calibration control high and low,lancets,lancing device,lancing device/lancets,bloodglucose meter,bloodglucose meter, wireless,jejunostomy tube,gastrostomy tube,dental plaque indicator,needleless dispensing pin,diaphragms, wide seal,heating pad,adhesive remover,gum mastic/storax/methyl salicylate/alcohol,syringe with needle,disposable,insulin 1 ml,syringe with needle,insulin,0.5 ml,condoms, latex, Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 304 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name prep iii-site-care dresng,ivex-2 filterset with ysite,veni-prep i kit,reliefband,twoway transfer device,venoset 78 w-mb piercing pin,hema access port,extension set,three-way stopcock ext 20in-sl,three-way stopcock ext 36,three-way stopcock,threeway stopcock wluer lock,threeway stopcock ext 20-sl,lifecare plum set,pca mini-bore set,pharmacy additive transfer set,y-type connecting set,extension set int-sl,brachial plexus tray,in-line burette set,venoset 78 wivex-2 nonvented,amnio centesis tray,4 leg vented transfer set,4 leg nonvented transfer set,3 leg vented transfer lubricated,activated charcoal/iron/sodium/water,s uppository mold,breast shield,adhesive,silver na hydrogen zirconium phos/hydrocolloid heel dressing,silver na hydrogen zirconium phos/hydrocolloid toe dressing,silver na hydrogen zircon phos/hydrocolloid heel&toe/cream59,nasal airflow strips,ear syringe,denture cleanser,adhesive tape,transparent dressing,facial mask,elastic bandage,pads for bedsores,nebulizer,peak flow meter/inhaler, assist devices,peak flow meter,condoms, latex, nonlubricated,sanitary pads,incontinence pad,liner,disp,ostomy supply,catheter,syringe disposable, irrigation,70 ml,urinary bag,urinary bag accessories,catheter male,external,drainage bag,gel dressing,catheterization tray,syringe disposable irrigation,colostomy bags,foam bandage,gauze bandage/elastic bandage,non-adherent bandage,ostomy adhesive,alginate Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 305 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name set,nutrimix iv empty container,extensi on tube,butterfly infusion set,platelet concentrate infusion,ivex h.p. filterset,s-a-i-f set 1 micron,clearcath,20g,2 in,clearcath,16g,1-1/4 in,clearcath,clearcath(subclav),abb ocath-t,abbocatht with syringe,butterfly,e xtension setlocking luer t,thoracentesis set,blood warming coil,y connector,inpers ol peritoneal cath. 11fr,blood collection set,doubleneedle transfer device,cont epidural wlidocaineepi,additive hinge cap,lifecare additive cap,male adapter plug,sterile empty vial,quik lok luer dressing,hydrocolloid dressing,zinc oxide,adhesive bandage,gauze bandage,syringe, disposable, 60 ml,syringe wneedle,disposab,3 ml,ostomy kit,syringe, disposable, 1 ml,underpads,diaper,brief,ad ult, disposable,syringe, disposable, 140 ml,syringe w-needle,disposab,1 ml,undercast padding,facialbody wipes,enema bag, disposable,wadding,syringe, disposable, 20 ml,syringe, disposable, 12 ml,needles, blood collection,syringe with needle, 12 ml,polyhexamethylene biguanide/gauze bandage,feeder container,eye patch,syringe, disposable, 3 ml,surgical suction tubing,compression stocking,thigh high,regular length,small,compression stocking,thigh high,short length,small,compression stocking,thigh high,regular length,medium,compression stocking,thigh high,regular length,large,compression stocking,thigh high,long length,small,compression stocking,thigh high,regular length,x-small,compression stocking,thigh high,short Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 306 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name lock adapter,sterile empty vial& injector,nv cardiac catheter set,microbore extension setsl,manifold 111sl,plum lc 5000 enteral set,pca extension set,pca set-long mini bore ol,pca cont inf mini-bore,pca set-cont inf mini bore ol,access set,catheter wcair clamp nonvent,cystomanom eter set,secondary irrigation set,t-u-r system w-flow pouch 2000,nonvented t-u-r set,cystoscopyirrigation set,nv large bore yirrigation set,pentothal dispensing pin,empty 3-in-1 mixing container,nutrimix -macro ferrules,ferrules,n utriclamp,container length, medium,compression stocking,thigh high,long length,x-small,wet dressing,compression stocking,thigh high,long length,medium,compression stocking,thigh high,long length,large,compression stocking,thigh high,short length,large,compression stocking,thigh high,regular length,x-large,compression stocking,thigh high,long length,xlarge,petrolatum,white,comp ression stocking, knee high, regular length, small,compression stocking, knee high, regular length, medium,compression stocking, knee high, regular length, large,compression stocking, knee high, regular length, x-large,compression stocking, knee high, long length, small,compression stocking, knee high, long length, medium,compression stocking, knee high,long length, large,compression stocking, knee high, long length, x-large,bismuth tribromophenate/petrolatum, white,syringe, disposable, 35 ml,syringe wneedle,disposb,0.5ml,syring e, disposable, 6 ml,syringe Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 307 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name with ytransfer,lifecare flex container,lifecare flex container 1000ml,adi sterile empty vial,snap lock device,veni loop connector,venose t 100-sl piggyback nv,burette 100ml hemoset nv,blood set w-pumpsl,pediatric microaggr blood filt,hema blood set,hema y-type blood set,microdrip micro pump setfiltr,soluset iv micro pump set,lifecare 5000 secondary cntnr,plum lc 5000 minipole,domepaste bandage,inspirea se,buf bodymate,actiprotect uf,novofine 32,novopen 3,novofine,novop en jr,innovo,novofine w-needle,disposab,6 ml,swab,syringe disposable irrig,60 ml,burn dressing,diaper/brief,infanttoddler, disposable,diaper,brief,yout h,disposable,feeder container w-gravity set,nasogastric tube,iodoform,needles, disposable,urinary bag/catheterization tray,calcium alginate,dressing, hydropolymer,porcine acell submucosa,meshed,porcine submucosa, fenestrated,peripheral nerve diagnostic device,nerve test monofilament,needles, insulin disposable, safety,diabetic supplies,miscell,vacuum erection device system,penile constriction ring systm,needles, insulin disposable,neurological exam pin,syringe, needle, safety,self-contained disposal unit,1.5 ml,syringe with needle, insulin,1 ml and sharps container,syring wndl,disp,insul,0.3 ml/container,empty,syring wndl,disp,insul,0.5 ml/container,empty,syringe with needle,insulin,0.3 ml,syringe with needle,insulin Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 308 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name autocover,novotw ist,nordipen 5,nordipen 15,astra selfaspirating dental,cartridge dispenser dental,astrapro,br eeze 2,autodisc normal,ascensia autodisc,fingersti x,glucolet 2,contour link,didget,contou r next link,microlet,singl e-let,microlet 2,contour,contour next ez,contour next control solution,contour next,contour usb,contour next usb,compat gravity delivery set,compat enteral delivery pump,vivonex jejunostomy kit,compat,compa t select flo pump,compat container wpump set,compat select flo case,compat select flo baggle cage,compat yset,iv disposable,0.3 ml,syringe, disposable, 5 ml,syringe, disposable, 10 ml,syringe, disposable, 30 ml,syringe, disposable, 50 ml,needles, safety huber, disposable,needles, huber disposable,needles, reusable,needles, huber reuse,needles, spinalanesthetic,needles, biopsy,bone,aspirate,syringe reusable, 0.25 ml,syringe reusable, 1 ml,syringe reusable, 2 ml,syringe reusable, 5 ml,syringe reusable, 10 ml,syringe reusable, 20 ml,syringe reusable, 30 ml,syringe reusable, 50 ml,syringe reusable, 3 ml,syringe reusable,syring w-needl 0.5 ml,kit-tray,syringe with needle 1 ml, disposable kittray,syringe with needle, 0.5 ml,syringe, irrigation, reusable,iv catheter kit accessory,syringe wcannula,disp, 3 ml,syringe w-cannula, disp, 5 ml,syringe w-cannula,disp, 10 ml,syringe with needle/cannula,disposable 10 ml,blunt needle, disposable,needles, filter,oral dosing devices,syringe, disposable, 2.5 ml,syringe,safety with needle,3 ml,syringe,safety Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 309 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name administration set,solution transfer device,beutlich ph test,hurricaine dispenser,hurrivie w,hurricaine luerlock,hurriview ii,hurricaine spry extension tube,pro-ception fertility pak,wide seal diaphragm,liqua spen,precise pain relieving,aerocha mber plus flowvu,detachol adhesive remover,mastisol, mastisol adhesive,boules quies earplugs,insulin syringe,ultra comfort,easytouch insulin syringe,condoms, thermacare,pump for liquagel,suppository mold,o-calette,pedi-skin adherent #2,pedipre,pedi-pre tape spray,hydro armor ag,hydro armor ag blister care,e-z ject with needle,1 ml,syringe,safety with needle,5 ml,syringe,safety with needle,10 ml,needles, safety,syringe with needle, 10 ml,syringe w-o needl,insulin,1 ml,syringe wneedle,disposab,5 ml,syringe with needle,insulin 0.3 ml (half unit mark),needle clipping and storage device,syringe with needle,insulin disposable,0.5 ml,pen needle, diabetic disposable, safety,blade lancet, safety,thermometer, glass mercury (oral),thermometer, glass mercury (rectal),iv catheter kit/iv catheter kit accessory,myelogram tray,pregnancy test kit,syringe with needle, insulin, safety, 1 ml,syringe with needle, insulin, safety, 0.5 ml,blood glucose calibration control solution, high and normal,bloodglucose calib. control,ringers solution,lactated/gel dressing,silver,dressing, odor absorbent, hydropolymer,mucus clearing device,compressor, for nebulizer,nebulizer/compres sor, for nebulizer,nebulizer accessories,spirometers and accessories,ostomy Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 310 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name lancets,major comfort,nasal strips,ear syringe,denture cleanser,micropo re first aid paper,micropore first aid skintone,micropor e first aid plastic,micropore first aid waterproof,micro pore first aid cloth,tegaderm,m icropore air wrming fltr mask,micropore pollen filter mask,micropore germ filter mask,coban,resto n,durex avanti bare,aeroeclipse ii,aerotrach plus,aerochambe r z-stat plus,aerochambe r with flowsignal,aeroge ar asthma action kit,truzone peak flow meter,aerochamb er mv,aerochamber mini,relion prime,relion confirm,trustex cap,colostomy washer,colostomy belt,ostomy disinfectant,karaya gum,urostomy pouch,colostomy bag, nonsterile,colostomy-ileostomy sets, non-sterile,colostomyileostomy sets, sterile,urostomy sets, nonsterile,urostomy sets, sterile,ostomy lubricating deodorant,condoms, female,sub-q administration set,sub-q infusion pump accessory,cervical cap,biosynthetic bandage,biosynthetic glove,ovulation test kit,blood-glucose meter & wrist blood pressure monitor,insulin pump cartridge,subcutaneous insulin pump,injection ports,insulin pump syringe, 3 ml,insulin pump syringe, 1.8 ml,blood ketone test,strips,blood glucose and ketone control, normal,sub-q insulin delivery device, 40 unit, disposable,sub-q insulin delivery device, 30 unit, disposable,sub-q insulin delivery device, 20 unit,disposable,middle ear inflation device,head support, infant, small,head support, infant, medium,head support, Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 311 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name condom,trustexria,trustex latex condom,trustex,f antasy,stayfree surefit,stayfree maxipad,stayfree ultra thin,carefree panty shield,tena serenity,serenity ultra plus,drain,bardic adaptertubing,cunningha m incontinence clamp,catheter,fe male intermittent catheter,toomey syringe,urethral catheter,reliaseal disc,dispoz-a-bag leg bag small,dispoz-abag leg bag medium,dispoza-bag leg bag large,leg bag holder,uro sheath disposable bulk,bardic uro sheath vinyl,male external catheter,deluxe fabric leg straps,catheter strap holder,twosided adhesive strips,latex extension infant, large,silver sulfate/non-adherent bandage,silver sulfate/foam bandage,foam heel dressing,dressing, foam matrix/activated charcoal,silver/calcium alginate,adhesive bandage/adhesive tape/benzalkonium chloride,adhesive bandage/adhesive remover comb. no.1,hydrocolloid dressing/adhesive remover comb. no.1,medical information identification tag,nasal exhalation resistance device,syringe, safety, self-contained disposal unit, 3 ml,syringe, safety, self-contained disposal unit, 5 ml,syringe,needle,insulin,saf ety,disposal unit,0.3 ml,insulin syringeneedle,safety,disposal unit,0.5 ml,syringe,needle,insulin,saf ety,disposal unit, 1 ml,syringe with needle, safety, self-cont disposal unit, 1 ml,syringe with needle, safety, self-cont disposal unit, 3 ml,syringe with needle, safety, self-cont disposal unit, 5 ml,syringe, safety, self-contained disposal unit, 10 ml,syringe,safety,disp Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 312 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name tubing,latex leg straps,bard center entry close system,urinary drainage bag,infection control bag,leg bag straps,bardex silicone foley catheter,rubber utility catheter,cleancath,protective barrier film,adhesive remover wipes,vigilon wound dressing,irrigation tray,basic irrigation tray,urethral catheter tray,bardex urethral catheter tray,universal foley catheter tray,davol complete foley kit,davol urinary drainage bag,bardia urinary drainage bag,davol foley cath insert tray,davol universal catheter tray,davol clsd unit,10 ml,conception assistance supplies combination no.1,bloodglucose transmitter,bloodglucose meter,continuous,bloodglucose sensor,bloodglucose meter,continuous/bloodglucose transmitter,syringe, disposable,syringe wcannula,disp, 1 ml,syringe w-cannula,disp, 6 ml,needles, pharmacy compound,syrng w-ndl,dsp kit-tray,0.5ml,syrng wndl,disp. kit-tray,1ml,syringe with needle,disposable,insulin,sy ringe wneedle,disposab,3ml,syringe wneedle,disposab,6ml,syringe ,safety with needle,12 ml,syringe with cannula,disposable 12 ml,syringe wneedle,disposable,syringe with needle, insulin, safety, 0.3 ml,feeder irrigation kit,yport adapter-extension set,pump set,calcium alginate/honey,soft lens surfactant cleanser,soft lens chemical disinfectnt,hard lens cleaner,gum/polyvinyl alcohol/dental adhesive,dental adhesive,toothpaste,dental Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 313 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name sys foley cath tray,davol irrigation syringe,davol irrigation tray,davol urethral catheter tray,davol silicone foley catheter,bardex closed system cath tray,infection control tray,bardex lubricath foley tray,extra colostomy pouch,stoma urine bag,extra security pouch,extra open-end drain,scanpor tape,opsite flexifix,allevyn,all evyn heel,profore,exudry,skin-bond cement,iv 3000,uni-solve adhes remover wipes,uni-solve adhesive remover,remove wipes,remove liquid,urikleen,skinprep,no sting skin prep,hypafix,opsit polishvarnishes,polymerized rosin resin,ovulation and pregnancy test kit,sodium chloride,thermometer probe covers,thermometer, electronic,oral,corn/callus cushion,dental floss,syringe w/needle,insulin disposable 0.3 ml (half unit mark),toothbrush,thermomet er, tape,ostomy accessories, filters and bridges,ice bag,cold-hot pack,finger splint,dental gingival products,hot water bottle,fountain syringes applicator,footcare,miscellan eous,thermometer, electronic,otic,hearing aid accessory,gloves, latex,blood pressure test kitmedium,blood pressure test kit,ear plugs,contact lens case,thermometer, basal electronic,tubular gauze/tub.rubbr dressing protector,blood pressure test kit-wrist,incontinence pants, reusable,blood pressure test kit medium and large cuffs,walker,silicone adhesive,infusion set for insulin pump,pharmacy dispensing adm set,pharmacy compounding access.,catheter accessories,external,syringe filter,enteral feeding Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 314 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name e postop,solosite,opsite flexigrid dressing,algisite m,transigel,replic are,viscopaste pb7,opsite adhesive dressing,flexigel, cicacare,primapore iv,primapore,covr site,covrsite plus,intrasite,alle vyn cavity dressing,allevyn tracheostomy dressing,unlabele d refill bottle 240ml,spray pump,microspon ge,monoject,mon oject syringe,sharpsafe ty container,nutripor t balloon,dover advantage,dover premium,dover pediatric urine,dover advantage drainage,monoje ct tb syringe,monoject luer lock tb syringe,curity lumbar puncture tray,durasorb,sim dispenser, 20 ml,enteral feeding dispenser, 35 ml,enteral feeding dispenser, 60 ml,enteral feeding dispenser,1 ml,enteral feeding dispenser,3 ml,enteral feeding dispenser,5 ml,enteral feeding dispenser,10 ml,dental suction device/chlorhexidine gl/dental swab comb no.1,dental suction device/chlorhexidine/dental swab #1/mouthwash,eye pressure monitor,injector device,spray applicator kit, sterile,humidifier,thermomet er, temple electronic,disinfectant,glycin e/sodium hydroxide,ultrasonic cleaner/holding solution,protease-amylase medical equipment cleaner,transfer device, closed system,needle injector, luer, closed system,needle injector, luer lock, closed system,connector luer lock, closed system,infusion adapter, closed system,ysite line connector, closed system,assembly system, vial to transfer device, closed system,clamp, iv tubing,diaper,brief,adult,disp osable,blood pressure test Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 315 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name plicity liner,telfa,maxicar e,rondic,presenc e,telfa clear,curity,kerlix, sure care protective underwear,monoj ect tb,curity maternity pad,curity ultramer 2-way catheter,webril,to uch-trol,curity cleaners medium,sharpsa-gator,enema bag,handicare,su recare,versalon,t enderskin,kendall paper tape,sure care protective undergmnt,curity foley catheter kit,curity cleaners large,dressing change-pov-iod tray,curity universal w-o drainage,suretys, monoject blood collection,confor m,monoject luer adapter,curity ureth cath closed systm,curity amd,curity urethral catheter,precision kitlarge,cane,wheelchair,smoki ng deterrent filter,cane tips,crutch accessories,crutch,thermom eter, basal glass mercury,neck collar,feminine syringe,vaporizer-humidifier supply,rectal syringe,nasal syringe,vehicle base no. 13,topical cream metereddose device,adapter cap for bottle,rectal, vaginal applicator tip,troche mold,silver/hydrocolloid dressing,fecal collector with charcoal filter,hard lens wetting solution,hard contact lens enzymatic cleanser/pf,arm brace,leg brace,back brace,compression socks, medium,compression socks, large,blood glucose calibration control solutions high,normal,low,aloe vera/gloves, latex,nonadherent bandage/petrolatum,white,fir st aid kit,dressing holder,blood-glucose meter, drum-type,prothrombin time test strips,amniotic fluid detection test,vaginal cream applicator,suppository container, empty,vaginal suppository applicator,filter, disposable ptfe membrane,benzalkonium Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 316 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name 200 catheter tray,argyle,nursin g pads (breast),webril ii,curity ultramer irrg 3way cath,curity o-b sponges,vistec,ar gyle connecting tubes,wings underpad,t.e.d. anti-embolism stocking,lisco,curi ty bedside drainage set,wetpruf,sharps a gator,curity ureth cath open system,tensor,ker lix amd bandage,urinary leg medium bag,kenguard,ad d-a-foley tray,foley catheter,curity irrigation tray,heavy drainage dressing steril,robinson clear vinyl catheter,specipan collection unit,vaseline petrolatum gauze,xeroform petrolatum dressing,xerofor chloride,allantoin,mineral oil/aloe vera/petrolatum,white/sodiu m lauryl sulfate,acemannan/alginate dressing,alginate dressing/carboxymethylcellu lose,needleless accessory device, insulin,blood sugar diagnostic test strips with disposable meter,safety seal, for bags,safety seal, for vials,safety seal, for syringes,defibrillator,automa tic,external,gel dressing/zinc acetate/meadowsweet/oak,c ellulose,oxidized/collagen,ac tivated charcoal/silver,gelmatrix pad dressing, silicone/benzalk chl/vit e/min oil,cholesterol calibration controls - high and low,cholesterol test, strips,cholesterol & blood glucose meter,prothrombin time/inr test meter,gel dressing, fenestrated,collagen,bovine, fecal collector w-charcoal filter/catheter/syringe, dispos,ostomy irrigator,activated charcoal/alginate dressing/hydrocolloid dressing,gravity feeding set,feeding pump,stethoscope,dental preparation, o.u.,bloodglucose transmitter/blood- Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 317 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name m,dermacea,der macea nonwoven,dermacea stretch,flexwrap,aquaflo,curit y thoracentesis trays,monoject pharmacy tray,curity thoracentesiscath tray,kenline add-a-foley tray 30cc,add-a-foley cath-pre-fill syrn,curity spng counter bag strips,curity spng counter rackscale,curad,curity surgical,clean catch-benzalkon towelets,clean catch-soap towelettes,t.e.d. sequnt compress device,copa hydrophilic foam,argyle trocar,unigard,wi ngs classic youth briefs,wings classic adult briefs,wings classic,wings choice plus youth briefs,wings choice plus adult briefs,wings choice adult glucose sensor,needles, subcutaneous set,iv administration set/needles, reusable,ring,cath male external-starter kit,transcutaneous electrical nerve stimulators (tens units),tens unit electrodes,blood pressure kit-extra large,propylene glycol,toe splint,disinfectant liquid soap cmb4,mineral oil/non-adherent bandage/petrolatum,hydrop hilic,weigh scale,blood pressure test kitsmall,compression socks, xlarge,blood-glucose and blood pressure beter with adult cuff,isopropyl alcohol,infusion set with insulin pump body,insulin pump controller,insulin pump/infusion set/bloodglucose meter,bacitracin zinc/polymyxin b sulfate,safety syringe with needle, disposable kit-tray, 1 ml,polyhexamethylene biguanide/non-adherent bandage,sub-q administration set, bifurcated,sub-q administration set, trifurcated,sub-q administration set, quadfurcated,alcohol swab cap,tubular bandage applicator,diaphragms, coil Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 318 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name brief,foley catheter tray,dover foley catheter,curity strmlin cath wmono-flo,curity premium catheter tray,add-a-foley cath-mono-flo drng,curity bedside-mono-flo drange,monoflo,tenderol,curity ureteral drain set,curity bedside drainage bag,simplicity adult poly,simplicity,ver salon washcloth,curity washcloths,curity urine meter,dover red rubber robibson cath,dover catheter,kendall,p olyskin ii,kerlix amd,dover bulb syringe,wings,ker lix burn pack,monoject safety syr tip cap,curity detectable lap,simplicity adult flat fold xl,dover latex foley spring,diaphragms, flat spring,cholesterol test kit,multiple test strip device,syringe, disposable, 1ml,syringe wneedle,disposab,12ml,rib belt,abdominal brace,compression pantyhose, small,compression pantyhose, medium,compression pantyhose, large,compression pantyhose,x-large,athletic support,bed pan,urinal,cushion,thermom eter, electronic (rectal),blunt filter cannula, disp.,soft lens enzymatic cleanser,transfer needle,hard lens soaking solution,incont device,muscle toner,elt,alginate dressing/hydrocolloid dressing,incontinence bed sheets,covers,venous flow controller,home hiv test kit,wetting soln gas,hard & soft,acne scrub pad,lumbar supports,contracept barrier dev, vented,gas perm. lens soaking soln,eye cup,plastic bags,chemo gowns,smocks,chemo spill clean-up kit,incontinence alarms,breast pump,iv equipment/container,empty, sterile field,chlorhexidine Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 319 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name catheter,simplicit y pants,curity run arounds,curity runarounds,curity sleep pants,kangaroo gravity set,excilon,tender sorb,kangaroo nasogastric feed tube,curasilk,diap ers-disppolyethylene back,dover urine leg bag,telfa amd,kangaroo epump set,curity iodoform,curity ultra fits,tenderwrap unna boot,kerlix lite,monoject insulin syringe,curity 8000 urine meter,hypodermi c needle,curity abdominal,curity ultramer catheter,rcra hazardous waste,kendall container,dover coated latex foley,curafil,kend all cloth,maxicare underpads,wings supreme,staput,wings gluconate,ring pessary,hard lens soak-wet solution,mercury spill cleanup kit,polyvinyl alcohol/gentian violet/methylene blue,silver/foam bandage,dressing,collagen/s ilver/sod alginate/carboxymethylcellul ose,dressing, collagen/sodium alginate/carboxymethylcellul ose,silver sulfadiazine/foam bandage,transcutaneous electrical nerve stimulators(tens)/electrodes, blood-glucose meter,for mobile device,transfer set/syringe, disposable/bandages,compr ession/tubing,gauze bandage/lanolin alc/min oil/petrolat/ceresin,zinc oxide/gauze bandage,polyquaternium6/gauze bandage,polyquaternium6/non-adherent bandage,polyquaternium6/adhesive bandage,honey/hydrocolloid dressing,eye drops dispenser,sub-q insulin pump, continuous glucose monitoring (cgm) syst,methylene blue/gentian violet/foam bandage,diaphragms, Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 320 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name maxima,wings fluff and polymer,curistrip,bandaid,non-stick pads,first aid tape,first aid cloth tape,first aid hurtfree wrap,mirasorb,ba nd-aid flexible fabric,gauze pads,rolled gauze,soothing non-stick,kling rolls,ultraheal,spe ctragel,lancets,co mfort lancets,super thin lancets,polymem, polywic,oasis ultra,curasol gel,curasol hydrogel,wound matrix,burn matrix,neuropen, neuropen monofilaments,ca reone,kinney brand lancets,thin lancets,ultra thin lancets,incontrol ultra thin lancets,unilet lancets,autolet mini,lancing device,advanced lancing device,unifine contoured,spirometer with drug delivery adapters,pen injector device,lancets with blood glucose test strips,thermometer, infrared, non-contact,foam/gauze bandage/lidocaine/chlorhexi dine/isopropyl alcohol Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 321 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value pentips,pen needle,incontrol pen needle,pen needles,healthy accents unifine pentip,autolet platforms,unifine pentips plus,unilet lancet,unilet gp lancet,alternate site lancets,unilet comfortouch,adv anced travel lancets,unilet excelite,unilet excelite ii,autolet lite clinisafe,unistik,a urora super thin lancets,incontrol super thin lancets,healthy accents unilet lancet,unistik 2,incontrol lancing device,autolet lancing device,healthy accents autolet,autolet mkii clinisafe,unistik 3,autoject 2,rapport vacuum therapy,amielle vaginal trainer,rapport BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 322 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value ring loading system,autopen,n eurotips,autodrop ,autosqueeze,ulti care syringe,ulticare,ul ticare pen needle,lancets thin,lancets ultra thin,fine 30 universal lancets,medlance plus,adjustable lancing device,insumed,i nsupen,glucosour ce,exel insulin syringe,insulin pen needle,tuberculin syringeneedle,exel tb with needle,exel tuberculin syringe,exel allergy syringe,allergy syringe,exel syringe,exel hypodermic needle,exel mti drawing needle,psv set,iv catheter,exel huber,exel huber needle,yale needle regular bevel,yale needle,yale BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 323 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value needle short bevel,special needle,intraveno us,arterial & blood,yale needle huber bevel,pudendal & parasympathetic, whitacre spinal needle,rosenthal, osgood,security bead needle, local,klatskin,yale glass tb syringe,yale syringe,syringe,c ornwall syringes luer-lok tip,plastic adapter kit for busher,cornwall accessories & parts,cornwall metal pipeting holder,tempaway thermometer sheath,yale spinal needle,quince spinal needle,allergist syringe,allergist syringe with needle,allergist tray,allergist syringe tray,tuberculin syringe,yale cleaner,asepto BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 324 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value bulb syringe glass tip,pipette 30ml catheter tip,pipette 45ml catheter tip,asepto bulb syringe cath tip,pipette 90ml catheter tip,pipette 120ml catheter tip,plastic adapter for busher,bulk syringe,syringe bulk,luer-lok syringe,needle,ca nnula,interlink syringe,lever lock cannula,twinpak dual cannula,interlink syringe wcannula,specialty use needles,regular bevel needles,needles, precisionglide,yal e needles,short bevel needles,blunt needle,thin wall needles,filter needle,tampertuf,oral syringe,nokor needle,nokor admix needle,cornwall BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 325 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value syringe tip connector,glaspa k,integra syringe,integra needle,sharps collector,onepiece sharps collectors,sharps container,safetylok safety syringes,safetylok safety syringe,medsaver ,syringe storage bin,eclipse needle,syringeneedle,eclipse syringe,eclipse syringeneedle,eclipse luer-lok syringe,safety syringeneedle,syringe tip cap,safetyglide needle,safetyglid e syringe,safetyglid e insulin syringe,safetyglid e tb syringe,safetyglid e allergy syringe,safetyglid e allergy,syringeluer tip cap,luerlok syringeneedle,safety-lok syringes,syringeBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 326 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value precisionglide needle,syringe catheter tip,tb syringe,luer-lok tip syringe,luerslip syringe,bd ultrafine pen needle,bd ultrafine,bd ultra-fine ii,lancet device,magniguide magnifier,safeclip,auto injector,autoshiel d pen needle,autoshield duo pen needle,paradigm link blood glucose,vacutain er blood transfer,luer-lok access device,bd microtainer lancets,microtain er lancets,safetylok collection set,vacutainer collection set,brite sight thermometer,insy te autoguard,insyte iv catheter,angiocat h iv catheter,angiocat BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 327 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value h,saf-t-intima iv catheter,saf-tintima,nexiva,intr osyte autoguard,qsyte,e-z set winged infusion set,saf-t e-z collection set,saft e-z set,myelogram tray,precise,ibgstar,haemolance, retractable,assur e id insulin safety,hypolance, advance intuition,assure pro,assure platinum,assure dose,assure 3,assure 4,glucocard expression,pocke tchem ez,multilancet device,micro,relio n micro,glucocard 01,glucocard 01 control,glucocard 01-mini,glucocard x-meter control,glucocard xmeter,glucocard vital,techlite lancets,techlite blood lancet,techlite,ha BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 328 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value emolance,assure haemolance plus,assure lance,haemolanc e plus,ultilet safety,ultilet classic,ultilet lancets,publix lancet,ultilet insulin syringe,ultilet pen needle,ultilet basic,suresite matrix,tenderwet active,tenderwet active cavity,evencare g2,safety lancets,pressure activated lancets,silvasorb, silvasorb cavity,exuderm odorshield,evenc are,skintegrity,me dfix ez,stratasorb,bor dered gauze,exuderm satin,evencare g3,medigrip,carra syn hydrogel wound,blenderm, transpore,microfo am,micropore,dur apore,steristrip,3m nexcare,tegader m i.v.,tegaderm BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 329 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value i.v. advanced,medipo re h,medipore dressit,medipore,soft cloth,medipore plus pad,steristrip wound closure syst,tegaderm hydrocolloid,tega derm hydrocolloid thin,tegasorb thin,tegagen hi,tegagen hg,tegaderm ag mesh,tegaderm absorbent,tegade rm hp,primeaire,qua ke,liteaire,mistern eb compressor,inspir ation elite,inspiration,si destream,mistern eb pediatric compressor,innos pire elegance,mistern eb nebulizer,sidestre am mask,innospire essence,micro elite replacement filter,minielite,mic ro elite,pflex trainer,assess,ast BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 330 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value hmapack i,asthmapack ii,asthmapack iii,asthmapack children's,thresho ld imt,threshold pep,asthma check,asthmame ntor,personal best,optihaler,opti chamber,pediatri c mask,sidestream plus,inspiration elite filter,micro plus,innospire replacement filter,sidestream nebulizer,sami the seal,litetouch,sa mi the seal filter,sami the seal mask,sidestream pediatric,optionho me,mini plus nebulizer,mini elite filter replacement,optic hamber diamond,procha mber,lo-profile urostomy pouch,contour i,filter security closed pouch,stoma cap w-micropore BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 331 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value adhesive,karaya drainable ostomy pouch,karaya seal closed stoma pouch,centerpoin tlock closed pouch,stoma cap w-deodor fltrflange,stoma cap w/deodor fltr/flange,karaya 5 drainable pouch,premium drainable pouch,skin barrier w-floating flange,convex syn barr w-float flange,pouchkins skin barrier,pouchkins pediatric belt,pouchkins pouch,pouchkins drain tube,pouchkins drainable pouch,pouchkins urostomy pouch,drainable pouch with flange,stoma irrigator drain wflange,drain pouch-filterflange,drainable pouch w-filtrflange,drainable BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 332 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value mini-pouch wflange,cpl drainable pouch,drainable pouch,urostomy pouch with flange,ostomy belt,urostomy drain tube adapter,hollihesiv e skin barrier,stoma combo cone-tube irrg kit,stoma cone w-connector unit,stoma combo cone,tube irrg drn,medical adhesive,adhesiv e remover,odor eliminator,m9clea nerdecrystallizer,sto ma lubricant,adhesiv e-barrier remover wipes,filter replacement,loop ostomy bridge, sterile,premium skin barrier,adapt barrier ring,softflex skin barrier,karaya,ad apt stoma powder,karaya paste tube,skin gel protective dressing,premier BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 333 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value drainable pouch,premier urostomy pouch,premier lock n roll,premier drainable minipouch,centerpoin tlock flextend skin,drainable pouch clamp,flextend skin barrier,premier urostomy pouch/flange,eve ryday male catheter,extende d male catheter,extensio n tubing wconnector,urinary leg bag,bag-strap system,bagtubing system,vent urin leg bag sys,combo pk,wound drainage collector,universa l catheter access port,drain-tube sterile clamp,horz drain-tube attach device,vertical drain-tube attach dev,suction tube attachment device,feeding BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 334 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value tube attachment device,replaceme nt neckband,retract ed penis pouch,fecal collector, drainable,bedside drainage collection,female urinary pouch,vented urinary leg bag system,fecal collector,new image skin barrier,new image flexwear,new image skin barrierflange,new image flextend,new image drainable pouch,new image irrigation sleeve,new image drainable mini-pouch,new image closed pouch,new image closed minipouch,new image,new image urostomy,new image urostomy pouch,new image colostomy-ileo kit,new image BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 335 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value kit,new image drainable kit,new image urostomy kit,adapt,adapt paste,adapt barrier,adapt convex barrier,premier closed minipouch,premier pre-sized minipouch,premier closed pouch,premier skn barr w-float flang,premier colostomyileostomy,premier urostomy,advanc e plus intermittent,incar e,fc condom, female,two-piece stoma caps,closed-end pouch,adhesive barriers,adhesive barrier,irrigation sleeve,microskin barrier,system pouch,microderm plus,one-piece drainable pouch,mini drainable pouch,urostomy pouch,platinum urostomy pouch,mini BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 336 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value urostomy pouch,one-piece urostomy pouch,microderm ,cymed seal,ilesorb,night drain adapter,microskin applicator,draina ble pouch closure,microhesi ve stoma paste,clickfine,reli on pen needles,thalaset, neria,insuflon,tub eguard,mouthpie ce,expiratory,piko 1,pocket peak,pocket chamber,pediatri c panda mask,panda mask,femcap,bio brane,biobrane dressing,biobran e-l,biobrane-l dressing,biobran e gloves,pillow mask,pillow mask for children,splash shield full,splash shield flex,splash shield short,co monitor replacement t,co monitor,disposabl e paper mouthpiece,miniBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 337 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value wright peak flow meter,airzone & miniwright afs,incheck oral,incheck nasal with mask,in-check dial,windmill trainer,one way mouthpiece,pedismall mouth adaptor,pediatric mouthpieces,airz one peak flow meter,one flow fvc,one flow spirometer,one flow mouthpiece,filtere d mouthpiece attachment,silico ne mask,breathrite,n ose clip,rubber mouthpiece,all flow 1000,all flow 2000,all flow 3000 pft,all flow 3000 kit,all flow 4000,all flow 5000,all flow 6000,all flow 7000,easygluco meter starter kit,easygluco,con trol,g-4,control solution,infinity,inf inity control solution,acura starter kit,acura BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 338 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value control solution normal,acura meter kit,acura control solution,acura control solution low,acura plus,easygluco plus,easygluco plus control normal,compact ultrasonic nebulizer,compac t compressor nebulizer,autolet impression,autole t plus,unistik czt,unistik 3 extra,unistik 3 comfort,unistik 3 neonatal,ultraco mfort,orsini insulin syringe,clearblue, easy pro plus,prodigy count-adose,prodigy mini-mist,prodigy pocket,prodigy,pr odigy eject,prodigy voice,prodigy duo,prodigy control solution,prodigy preferred,prodigy autocode pro,prodigy BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 339 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value pocket pro,prodigy voice pro,prodigy twist top lancet,prodigy lancets,prodigy lancing device,prodigy pen needle,prodigy insulin syringe,actilance,droplet lancets,easy touch glucose monitor,easy touch lancing device,easy touch control solution,easy touch,easy touch insulin syringe,easy touch pen needle,omnipod, 1st choice lancets,1st tier unilet comfortouch,1st tier unifine pentips,1st tier unifine pentips plus,iport,thinset,fifty50 safety seal lancets,fifty50 reservoir,infusion set,eclipse,eclips e control solution,envision, BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 340 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value evolution blood glucose meter,evolution control solution,element blood glucose meter,element control solution,smartdia betes xpres,smartdiabe tes vantage,element plus,xpres,eleme nt plus control solution,glucolab control,glucolab,s martest,smartest lancet,smartest eject,smartest protege,smartest smart code,smartest talking,smartest pronto,smartest persona,glucoco m blood glucose,glucoco m lancets,blood glucose meter,glucocom control solution,glucoco m,glucocom autolink,glucose control solution,glucose control,bloodglucose BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 341 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value control,rightest gm300 system,bionime rightest gm300 system,rightest control solution,rightest gd500,rightest gm100 system,rightest gm550 system,rightest gl300 lancets,ge100 blood glucose system,ge100 control solution normal,nova sureflex,sureflex, nova max blood glucose meter,nova max glucose control soln,novamax plus,novamax plus glu-ket,nova safety lancets,keynote, wavesense control solution,agamatri x control,jazz wireless 2,wavesense presto,keynote pro,wavesense amp,presto pro,liberty blood glucose BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 342 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value meter,liberty control solution,vgo 40,vgo 30,vgo 20,ear popper,sterilance tl,cinis preemie halo,restore contact layer,restore contact layer silver,restore,rest ore trio,restore duo,restore foam heel dressing,restore odorabsorbent,restore ex thin hydrocolloid,resto re hydrocolloid dressing,restore calcium alginate,restore hydrogel,restore hydrogel gauze,ultraflex,burns-scaldsabrasions,skin closure,blister care,bandages,m edical id for bracelet,medical id for necklace,riteflo,pr ovent hr,provent sr,provent,ultratra k pro,ultratrak,ultral BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 343 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value ance,ultratrak ultimate,safesnap syringe,safesnap insulin syringe,safesnap tuberculin syringe,safesnap allergy syringe,conceptio n,needle-pro edge,solus v2,solus v2 lancets,solus v2 lancing device,solus v2 control solution,caresens n,caresens,smart caresens n,invacare lancets,gdrive,de xcom g4,seven plus,seven system sensor,droplet lancing device,syringe without needle,filter connector,lifeshie ld blunt cannula,transfer needle,bone marrow aspir needle,filter aspirator needle,allergist tray syr-perm needle,monoject BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 344 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value allergy trayneedle,monoject tuberculin syringe,allergist tray syr-detach ndl,monoject insulin safety syrng,monoject tuberculin safety syr,monoject control syringe,monoject syringe pharmacy tray,monoject safety syringe,safety syringe with shield,monoject smartip cannula,monolet lancets,monoject or lancet device,monolet thin lancets,sharps container accessory,glove box,monoject magellan,finger grip extender,magella n tuberculin syringe,monoject megellan tb syringe,magellan insulin safety syrng,magellan insulin syringe,oral BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 345 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value medication syringe,extender caps,kangaroo pet carrying case,kangaroo pet pump frame,kangaroo pet charging cord,petrolatum gauze,xeroflo gauze dressing,viasorb, blisterfilm,ultec,qtips wood stick applicator,interso rb,expandover,ka ngaroo enteralfeed-irrig kt,kangaroo pump extension set,kangaroo 500ml pump set,kangaroo deluxe pump set,kangaroo pump set,kangaroo 1000ml gravity bag,kangaroo 1200ml deluxe pump st,kangaroo proximal spike pmp st,kangaroo screw cap pump set,kangaroo 1600ml deluxe pump st,kangaroo y-site BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 346 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value extension set,kangaroo 1200ml rigid containr,kangaro o rigid container,kangar oo plyurethane feed tube,kangaroo 100ml rigid burette,texas catheter,elastic foam strap,uridrain,two-sided adhesive strap,catheter with strap,vaseline constant care,rob-nel pvc catheter,terumo insulin syringe,terumo surguard2,thinpro insulin syringe,terumo surguard,terumo allergy syringe,terumo syringe,terumo hypodermic needlesyrin,medihoney, premier skn barr w/float flang,sensitive eyes saline,sensitive eyes BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 347 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value drops,sensitive eyes plus saline,sensitive eyes daily cleaner,renu multi-purpose,bio true,renu rewetting drops,renu multiplus,boston advance cleaner,boston conditioning solution,boston simplus solution,re-nu fresh,boston cleaner,smoker's polident,polident, super poligrip,sensodyne,d entucreme,dentugel,super wernet's denture,ctub,gallon jug with pump,jetcospray cannula,dee fog,zarosen,varn al,release,mixing container with lid,reveal pregnancy test,reveal ovulation predictor,stik it,reveal blood BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 348 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value glucose meter,reveal get pregnant quick,reveal ovulation test,mesalt,mepil ex,tendra mepilex border,probe covers,digital thermometer,und erpad,bladder control pad,water shield bandages,antibac terial bandages,foam bandages,gauze bandage,stretch gauze bandage,shield,u ndergarment,brief ,lamb's wool,fabric bandage,adhesiv e pads,clear bandages,flexible bandages,plastic bandages,banda ges sheer,callus pads,sheer bandages,sterile pads,adhesive tape,dental adhesive,hypoallergenic bandages,cotton swabs,color lancets,cosmetic puffs,cosmetic BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 349 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value squares,dental floss,flexible bandage,elastic bandage,baby wipes,pregnancy test,strong strips,waterproof strong strips,multipurpos e contact lens soln,saline solution,saline sensitive eyes,fever flash thermometer,dent ure,combine abd,toothbrush precision head,toothpaste, cotton balls,bandage,cot ton squares,cosmetic balls,toothbrush adult deluxe,lens lustre eyeglass cleaner,toothbrus h, total,pill box,pill planner,pill divider with pill box,medicine dropper,medicine spoon,forehead thermometer,ther mometer,thermo meter probe covers,brief, medium,ep brief,heatwraps,b BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 350 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value andage roll,breatherite,o. a.d.,woun'dres,co mfeel plus,comfeel plus clear,comfeel plus triangle,comfeel plus contour,comfeel plus pressure relief,comfeel ulcer care,comfeel,com feel film,female self catheter,selfcath,coloplast skin barrier,coloplast paste,ostomy paste,coloplast barrier ring,coloplast,col oplast drainable pouch,coloplast closed pouch,irrigation set,assura irrigation face plate,assura 2pc irrigation sleeve,filtrodor pouch filter,pouch clamp,assura flange,assura wound manager,assura, assura flange convex,assura BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 351 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value ostomy belt,comfeel seasorb,assura 2pc drainable,assura pouch,assura standard wear,assura pediatric pouch,comfeel purilon,conveen coude intermtnt cath,conveen drip collector,assura easiclose,assura non-convex drainable,urosto my night bag,biatain,assur a extra,assura two-piece uro minicap,assura light easiclose drain,assura ac,urostomy multichamber,urostom y multi-chamber pouch,urostomy micropouch,easiclose wide outlet,coloplast paste strip,sensura easiclose wide outlet,sensura click ostomy pouch,sensura BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 352 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value flex ostomy base plate,sensura ostomy base plate,sensura flex ostomy pouch,ice bag,overnites,sur e choice pantiliners,belted undergarment,wi pes,diapers,sensi tive baby wipes,bladder control pads for women,briefs for men & women,ezject lancets,panty shields,tugaboos diapers,maxi pads,panty liners,hot-cold compress,multiuse cold pad,back & neck cold pad,cloth first aid tape,selfgrip,finge r splints,finger sleeves,rewetting ,super strip bandages,flexible fabric bandage,flexible fabric bandages,tugabo os overnights,under wear for men,premium BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 353 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value baby wipes,clear spot bandages,ovulati on predictor,kid pants,protective underwear,surec hoice,pantiliners, dental travel pack,briefs xlarge,cotton, sterile,sheer plastic strip,disposable razor,adhesive bandage,fabric strip extra large,pro sports tape,ice cap,water bottle,water bottle-fountain syringe,foam insole,cushion insole,super moleskin,over nites,instant ear thermometer,viny l gloves,multipurpose solution,eye patch,instant heat therapy,hearing aid batteries,latex gloves,true2go blood glucose system,self grip,cotton gloves,underpads ,soft touch pill BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 354 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value reminder,linen fresh,hot & cold therapy brace,instant heat,heat therapy patches,moist towelettes,ultra fine cut n crush,tablet cutter,nail clip,toenail clip,nail nippers,disposabl e probe covers,alkaline batteries,toenail nipper,finger splint,tubular gauze,non-slip underpads,delux e underpads,blood pressure monitor,underwe ar for women,foam ear plugs,guards for men,underwear menwomen,blood pressure cuff monitor,boxers for men,surgical dressing,contact lens cases,paper tape,cleaning & disinfecting lens,callus cushions,plantar BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 355 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value fasciitis arch sleeve,gel bunion cushion,clear bandage,pain free tape,flexible foam pad,push n pop pill reminder,medicin e dropper & spoon,am-pm locking pill reminder,soft-tip thermometer,und erwear for men & women,tugaboos training pants,quiet please foam ear plugs,blood glucose monitor,flexible foam bandage,disposa ble brief,daily cleaner,rewetting drops,one step ovulation test,truetrack smart system,gauze,bla dder control,heat wraps,basal thermometer,hyp o-allergenic bandage,blood pressure kit,tender tape,skin closure strips,flex fabric BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 356 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value bandage,comfortstretch,premium comfortstretch,gauze dressing,one step pregnancy test,comfortsmooth,fitted briefs,fitted brief,blister relief,ultra-soft gloves,premium nitrile gloves,quick read,adult wash,certainty,to e separators,gel toe spacers,gel toe protector,arch bandage,gel corn protectors,sleep pants,truetrack blood glucose system,trueresult blood glucose systm,flight ear plugs,sterile bandage roll,gentle adhesive bandages,plastic adhesive bandages,sheer adhesive bandages,confor ming rolled gauze,deluxe arm bp monitor,premium BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 357 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value arm bp monitor,premium baby diaper,premium training pants,flushable cleansing cloths,face mask,non-stick pad,micro thin lancets,ultra-light rollator,scar treatment,cloth tape,trueplus lancets,pain free wrap,self adherent wrap,gel bunion guard,sorespot,al l gel bunion toe spreader,well beginnings sleep pants,e.p.t.,e.p.t. digital,e-z spacer,vanishpoi nt,syringe with needle disp,sheer spot bandages,blood glucose monitoring,premi um blood glucose,accuchek spirit,sew-in pocket,accu-chek tender,accu-chek rapid d,accuchek,d-tronplus adapter,accuBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 358 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value chek ultraflex,accuchek ultraflex ii,sport belt,accuchek d-tron plus,flexlink plus infusion set,foracare gd20,choicedm g20,fora v30a,fora g71a,foracare gd40a,foracare gd40b,premium v10,fora v12,kimono,kimo no maxx,kimono microthin,kimono microthin aqua lube,kimono textured,digitex gold,rid,devilbiss pulmomate,pulm o-aide,devilbiss pulmoaide,devilbiss disposable nebulizer,devilbis s compact,sunrise compressornebulizer,devilbis s traveler,cytosafe dipensing pin,exactamed,dual rate syringe infuser,bifurcated BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 359 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value fluid tran tube set,exactamix,elbow inlet,gravity mixing set,luer lock-to-bag,fluid transfer extension set,vial adapter,bag spike,oral liquid transfer tube set,micro volume inlet,fluid transfer set,calibration bag,dual rate syr infuser tubing,minibore, microfuse minibore,pole clamp,em2400 valve set,exactamix calibration,exacta -mix eva,micromacro,s terl fluid transfer tube set,topical tip cap,topical cream dispenser,topical dispenser,sterile fluid tran tube set,syringe filling fixture,oral liq bag-tube set combo,repeater pump stand,pharmacy pump stand,0.2 BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 360 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value micron filter attachment,gel bag & tube set non-sterile,sterile exacta-med dispenspin,tamperresistant bag cap,sterile top fill bag,sterile empty collection bags,adaptacap,microfuse,trif urcate fluid tran tube set,pharmacy pack liquid dispenser,repeat er pump,vaginal cream dispenser,luer to urethral tip adapter,luer to catheter tip adapter,sterile rapid fill connector,sterile gel bag,sterile two-fer needle,exactamed tip extender,supor,la bels, 1.5" x 1.5",kwikvial,kwik-vial filling extension,kwikvial plug dispenser,t.i. seal BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 361 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value non-sterile foil,bottle adapter,3-way oral port stopcock,rapid fill adapter,sterile rapid fill adapter,oral-tooral rapid fill connec,mark-adose,oral labels,shrinksafe, port saver sterile inject port,vaginal dispenser tip cap,tip caps, nonsterile,exactamed tip cap,luer lock tip cap,luer lock tip caps, sterile,sterile luer slip tip caps,luer slip tip caps,selfrighting luer slip tip,catheter tip cap,locking,selfrighting luer tip cap,self-righting luer lock tip,bedside pack liquid dispenser,ward pack liquid dispenser,neothri ve,rapidfill,comfort bath,toothette,qcare rx,reality,first aid paper BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 362 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value tape,first aid skintone paper,first aid plastic tape,first aid waterproof tape,air warming mask,dust & pollen filter mask,germ filter protective mask,cold comfort,trueplus insulin syringe,brush 'n floss,proview eye pressure monitor,autolancet mini,injectease,insuleze,insulcap,insultray,reconstitube, deluxe tablet cutter,zymogeneti cs spray applicator,vicks warm steam vaporizer,health mist,vicks cool mist,vicks warm mist,vaporizer,vic ks digital thermometer,vick s forehead thermometer,ther moscan,cetylcide g,hyde-out,power cleaner,cetylzyme,replacemen BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 363 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value t j-4 cannula,mepilex border,mepilex ag,mepilex border sacrum,mefix,lite touch,medilance,aurora healthcare lancets,phaseal protector,phaseal injector luer,phaseal connector luer,phaseal adapter,phaseal y-site,phaseal assembly fixture,phaseal infusion,phaseal secondary set,saline,kotex fresh & dry,kotex overnight,depend ,huggies,huggies pull-ups,huggies baby wipes,goodnites, depend silhouette,depend real fit,poise pads,depend guards for men,kotex security,poise liners,depend overnite,depend protection,huggie s BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 364 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value goodnites,goodnit es sleep shorts,huggies ultratrim,lavender nitrile exam glove,huggies overnites,topcare belted shield,topcare underpad,topcare maxi overnight,topcare pantiliner,topcare male guard,topcare liners,topcare pads,topcare maxi pads,luvs,pamper s premium,pamper s ultra dry thin,pampers babydry,pampers unisex,pampers cruisers,underja ms,pampers easy ups,pampers extra protection,pampe rs swaddlers sensitive,pamper s preemie,pampers swaddlers,pampe rs,newborn babydry,washcloth,pa mpers BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 365 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value premature,pampe rs ultra dry,pampers newborn,pamper s rash care,pampers premie,luvs overnight,pamper s nonelasticized,pamp ers ultra phases,ultra + pampers,pamper s thick phases,pads,refu ah plus,refuah plus glucose control,sleep overs,cuties,cutie pants,glucopro,a migo insulin pump,hugo cane,hugo rolling walker,hugo transport,hugo folding walker,airgo rolling walker,universal 1,smart sense lancets,topcare universal1 thin lancet,ultra thin plus,smart sense,ultra thin plus lancets,topcare ultra comfort,renew BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 366 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value advanced microlancets,renew advanced lancing system,topcare clickfine,bullseye mini safety lancets,sms glucose control,safetylet,safety seal lancets,aqua lance lancing device,easy twist & cap lancets,surechek glucose control,sure edge blood glucose meter,sure edge glucose control soln,alternate site lancing device,vocalpoint glucose control,vocal point glucose control,one step at a time,cane tips,cane,crutch tip,hand grips,crutch accessory kit,underwear,hu midifier,crutch,co ol mist,super underpad,regular pad,super pad,cervical collar,oral BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 367 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value thermometer,bab y thermometer,femi nine combination syringe,fountain syringe,feminine folding syringe,feminine bulb syringe,vaporizer inhalant,vaporizer cleaning tablets,feminine compact travel syrnge,attachme nt set,enema syringe,nasal aspirator,rectal syringe,wheelcha ir,acapella,lipo cream base,shrink band,plastic white hdpe bottle,amber round glass bottle,topiclick,bottletop dispenser adapter,unguator lid,syringe filter, millexgp,precisedose dispenser tip cap,megapump mezzo,megapum p airless,rectalvaginal perforation BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 368 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value tip,sterile clear glass vial,amber glass serum bottle,topi-click filling nozzle,enema bottle,adapter cap,glass graduated cylinder,precised ose dispenser syringe,posidyne eld,suppository shell,syringe filter, millexgs,adapter pressin bottle,troche mold,thermophor e,thermophore maxheat,ice it!,thermophore arthritis,opsite iv 3000,no-sting skin-prep swab,exu-dry slit tube,conformant 2,drynet,replicare ultra,replicare ultra sacrum,acticoat,a cticoat 7,acticoat absorbent,aquap hor gauze,hot & cold compress,sports tape,ear thermometer,non adherent pads,nonBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 369 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value adherent,adhesiv e bandages,adhesi ve foam bandages,baby darlings wipes,baby darlings diapers,combinati on water bottle,thong liners,tampons,ex tra absorbent undergarment,pu re cotton,feminine cleansing cloths,lice removal comb,heating pad,personal washcloths,traini ng pants,compmist compressor nebulizer,minico mp compressor nebulizer,earloop masks,cone masks,instant cold pack,transport chair,selfgrip,deluxe instant,lubricating & rewetting,everyda y long pantiliners,sheer BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 370 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value strips,clear strips,plastic strips,personal confidence pads,beltless undergarments,p ersonal confidence briefs,overnight brief,personal confidence underpad,flexible foam strips,slipon undergarments,b aby basics,basics for kids,butterfly closures,heavy duty fabric strips,personal confidence liners,overnight protective,clear waterproof strips,natural care bandages,camo bandages,person al confidence underwear,protec tive barrier wipes,reliamed,re liamed mini lancing device,reliamed safety seal lancets,transpare nt thin film dressing,transpar BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 371 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value ent i.v. site dressing,ostomy protective powder,incontrol bp monitor,microlife peak flow,stomahesive protective,flexiseal fecal,surepress,ul ti-lance,lc d nebulizer set,lc plus,baby nebulizer,lc star,sinustar,pari lc plus nebulizer,lc sprint nebulizer,pari sinus aerosol system,pari lc sprint sinus,vios aerosol delivery system,filter, valve set for ll & lc,filter pad,filters replacement,bab y conversion pack 1,baby conversion pack 2,mask set with y-piece,mask vortex,vortex,bub bles the fish ii,wing tip tubing,adult aerosol mask,vortex ladybug BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 372 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value mask,vortex frog mask,trek s portable pwr kit,trek s combo pack,trek s compact compressor,alter a nebulizer,eflow scf,eflow scf aerosol head,eflow scf nebulizer handset,smartma sk kids,proneb ultra,proneb ultra ii,proneb ultra ii deluxe,elasto-gel hot & cold wrap,elastogel,elasto-gel plus,toe aid dressing,elastogel circle dressing,elastogel cast-splint padding,boston rewetting drops,boston one step,microspacer, microchamber,ea symax v speaking,easyma x v,easymax speaking,easyma x v2,easymax l,easymax n,easymax,easy max ng,easymax 15,easyplus BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 373 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value r13n,easyplus v,anti-embolism stockings,truform compression stocking,puralin,s urgilance lancets,cut n crush,moist wipes,cold wrap,cold pack back pad,tennis elbow brace,ankle brace,elbow support,knee brace,ace back support,knee stabilizer,elbow strap,wrist support,ankle support,ace ankle support,arm sling,elbow brace,knee support,deluxe laced ankle brace,backshoulder ice & heat wrap,multipurpose ice & heat wrap,wrist brace,deluxe ankle brace,contoured back support,back stabilizer,deluxe back stabilizer,maxi BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 374 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value super,maxi deodorant,maxi regular,thumb stabilizer,deluxe wrist stabilizer,hand support,warm steam vaporizer,selfadhering,flushabl e moist wipes,ankle stabilizer,ace aerosol cloud enhancer,easiven t,daily pill box,hot & cold pack,medilice,sheer adhesive,medico ol's diasox,thermipaq, myglucohealth,m yglucohealth lancets,myglucoh ealth control solution,nessi spacer,protective pads,jumbo diapers,supreme diapers,diapers mega,kidpant,abs orbent cotton balls,stretch bandage,sheer strip,blood glucose monitor kit,bladder control pad ultra,guard BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 375 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value male,plastic swabs,diaper,inst ant cold therapy wrap,sleep comforts,gentle tape,gloves,nonadhesive pad,overnight briefs,cleansing wipes,saline sensitive,aloe vera latex gloves,flexible dressing,gauze sponges,eye pad,adhesive dressing,selfadherent gentle wrap,blood pressure cuff,contact lens relief,flex bandage,ear plugs,suresite window,procedur al face masks,advanced non-stick dressings,nonstick dressings,surgica l dressings,allpurpose dressings,dressin g sponges,cold pack,x-abs underwear,foam toe bandages,all purpose cloth BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 376 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value tape,corn cushion,flex finger bandage,callus cushion,moleskin plus,first aid kit,nitrile exam gloves,portable sharps disposal,triple layer non-stick pad,qwikstrip,premium adult wash cloths,peas cold therapy,arthritis heatwraps,calciu m alginate,hydrogel dressing,hydrocol loid dressing,contact lens case,household burn kit,reusable instant heat pack,elastic stretch net,women's underwear,men's underwear,weekl y vitamin planner,saline 4,disposable latex-free gloves,overnites diaper,adhesive gauze pad,needle BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 377 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value collection & disposal,rolled absorbent cotton,iv prep antiseptic,coverle t o.r.,allevyn plus,blairex sterile saline soln,assess peak flow meter,personal best peak flow meter,coaguchek ,accu-chek safet-pro plus,chemstrip bg diary,soft touch,accu-chek voicemate,accuchek safe-tpro,softclix,accuchek softclix,microdot, 3m nexcare stomaseal,microp ore paper surgical tape,blenderm surgical tape,durapore cloth surgical tape,opticlude,sto maseal,nexcare gentle paper tape,3m nexcare durapore,nexcare all purpose mask,futuro restoring,futuro BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 378 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value antiembolism,nexcar e tegaderm,paper first aid tape,amniscreen, metercheck,normject,aimsco,aimsc o ultra thin ii,aimsco mini ultra-thin ii,ultrathin ii,ultra thin ii,ultra-thin ii lancets,pcca accupen15,supposistrip,u niversal sleeve,vaginal cream applicator,suppos itory box,filter, millex-or syringe,boston round natural,vaginal suppository applicator,bottle,l uer lock adapter,filter, millex-fg 0.2um,suppositor y shell, small,suppository shell, medium,syringe tip rectalvaginal,freedom precision airless,advanced BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 379 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value antibacterial bandage,antibact erial bandage,antibact erial pad,temple thermometer,fast read thermometer,chil d ear syringe,infant ear syringe,watchhal er,carra sorb h,carra sorb m,carra film,diab,pump for whirlpool solution,shampoo & body wash dispenser,radiafd g,carrasyn gel,gauze packing strip,wound dressing,gel pad,carrasyn spray gel,carra gauze strips,carra gauze,carrasyn v,carracolloid,ultr a-klenz,dermal wound gel,primary dressing,incontin ence skin care,carrasmart,c arradres,radiadre s,carraginate,sur esite BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 380 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value iv,suresite,suresit e flexigrid,arglaes,a rglaes film,arglaes island,optifoam,e xuderm rcd,exuderm,exu derm lp,exuderm ultra,exuderm sacrum,dermagel,medfix,maxor b,maxorb extra,tenderwet,e z smart,ez smart lancets,ez smart plus,onetouch ultra control soln,one touch delica,onetouch verio iq,one touch verio,onetouch delica,onetouch finepoint lancets,onetouch suresoft,onetouc h ultramini,onetouc h ultra system,one touch glucose control soln,onetouch verio,one touch basic system,surestep, penlet plus blood sampler,onetouc h lancets,onetouch BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 381 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value ultra2,onetouch ultra smart,onetouch ultralink,surestep control solution,surestep pro,grx wound gel,alligator spoon,pre-moist pads,replacemen t pads,aerochamb er,one touch lancets,ultra fine lancets,opsite flexigrid,opsite,all evyn cavity wound dress,algisite,unif lex,needle free syringe kit a,medi-jector vision,needle free syringe kit b,needle free syringe kit c,medi-jector needle-free syr a,medi-jector needle-free syr b,medi-jector needle-free syr c,truedraw,starter kit,life medical starter,diabetic.co m starter,prestige meter,prestige,pr estige value pack,truetrack,tru BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 382 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value econtrol,truetest glucose control,sidekick,p restige smart system,prestige smart system iq,liberty lev 1 glucose control,liberty lev 2 glucose control,liberty monitor,breathe right,medisense thin lancets,medisens e glucose ketone,medisens e glucose ketone contr,medisense, precision xtra,optium,precis ion,unistik 2 normal,unistik 2 extra,steritamp,elon nail care system,flutter,2te k,e-z spacer pedspak,wonderp ants,up & up maxi pads,up & up baby diaper,telcare,telc are control solution,sure-ject insulin syringe,surelance,sure-fine pen BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 383 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value needles,sure-test easyplus mini,suretouch,surepen,heartstream fr2,deltec cozmo,infusion,in sulin cartridge,adapter, belt clip,gripper plus,deltec cozmo cleo infusion set,amerigel,der mafilmhd,dermasyn,der magauze,dermav iew,dermaview ii,dermafilm,derm aginate,dermadre ss,dermalevin,fle xzan adhesive dressing,hydrocol ii,sorbsan,vial,ste rile,empty,maxifill transfer set,iv transfer spike,steri-tamp seal,chemo transfer pin,floweze,mini transfer pin,hi-volume pumping chamber,transfer pin,universal syringe tip adaptor,promogr an prisma,promogra BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 384 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value n,actisorb,silverc el,tear flo,scar care,accu-chek aviva plus,coaguchek xs,accutrend cholesterol,accutr end glucose,accutren d plus,accu-chek fastclix,accu-chek compact blue control,coaguche k xs pro,accuchek nano smartview,accuchek smartview,comfor t,cartridge pump,contact detach infusion set,cartridge stamped,onetouc h ping,insulin pump,cartridge,in set infusion set,animas 2020,inset 30 tubing,infusion pump,comfort short,inset 30 infusion set,ultima,gelpad, woundgard gauze,coolmagic, triple helix collagen,foam dressing,sanizone ostomy BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 385 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value deodorant,primab ella,flexi-seal fms,little ones active life pouch,active life drainable pouch,active life urostomy pouch,sur-fit natura stomahesive,acti ve life convex,kaltostat, kaltostat fortex,active life stoma cap,active life closed-end pouch,duoderm cgf,combiderm acd,sur-fit autolock stomahesive,surfit autolock durahesive,sur-fit autolock drain pouch,sur-fit autolock pouch,sur-fit natura drainable pouch,sur-fit natura closedend pch,sur-fit natura minipouch,sur-fit natura urostomy pouch,sur-fit natura pouch,surfit natura high output,sur-fit BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 386 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value autolock,sur-fit natura durahesive,sur-fit natura flange cap,visi-flow irrigation sleeve,visi-flow irrig starter set,sur-fit nat irrig faceplate,sur-fit natura little ones,little ones drainable pouch,little ones urostomy pouch,little ones closed-end pouch,visi-flow irrigator stoma cone,carboflex,aq uacel-ag,esteem synergy,stomahe sive,durahesive moldable convex,esteem drainable pouch,little ones skin barrier,duoderm hydroactive,duod erm,visi-flow sleeve tail closures,visi-flow stoma cone,convatec night drainage tubing,sur-fit natura convex inserts,ostomy BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 387 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value appliance belt,sur-fit-act life-tail closures,aquacel, duoderm signal,versiva,ver siva xc,allkare adhesive remover wipes,allkare protect barrier wipe,flexi-trak anchoring device,unnaflex,saf-gel,sur-fit autolock inserts,sur-fit natura adaptor,sur-fit natura lowpressure,duolock curved tail closure,eakin cohesive seals,convatec night drain container,esteem + closed pouch,esteem closed pouch,natura closed pouch,esteem synergy closed pouch,flexi-seal signal fms,stomahesive skin barrier,eakin cohesive BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 388 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value slims,aquacel foam,natura durahesive skin barrier,natura stomahesive skn barrier,aquacel extra,harmonie,dr y comfort extra,tena,dry comfort,tena pants,tena classic,tena stretch ultra,tena classic plus,tena protective underwear,flexiflo ,y-port connector,flexiflo top-fill,flexiflo feeding tube,flexiflo topfill bag,enteralite infinity,flexiflo magnaport,magnaport,flexiflo overtheguidewire,flexiflo easy-feed 500,flexiflo top-fill enteral bag,flexiflo quantum,compan ion pump,durag,nasoenteric tube,embrace,em brace adapter,embrace bag set,flexiflo BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 389 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value toptainer,flexiflo feeding bag,embrace pole clamp,quantum pump,patrol,gravi ty feeding set,tranquility premium underwear,atn brief,select underwear,select disposable briefs,select underpads,diaper booster pad,tranquility topliner pads,select kids briefs,self-taking blood pressure,a.i.r.s. nebulizer,airs disposable nebulizer,airs adult aerosol mask,airs pediatric disposable mask,comp-air elite compressor syst,reusable nebulizer kit,air tube with air plugs,micro air,comp-air nebulizer compressor,peak -air,women's BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 390 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value advanced bp monitor,stethosco pe,visine for contacts,bengay moist heat therapy,ezo,avog el,sofsensor,guardian transmitter tape,guardian rt starter kit,paradigm realtime,guardian realtime,guardian rt system,replacem ent pediatric monitor,minimed reservoir,1.5 volt batteries #357,polyfin,sofset,paradigm insulin pump pathway,polyfin qr,sofserter,paradigm infusion,quick release soft teflon,sof-set micro,paradigm,p aradigm silhouette,silhoue tte,silserter,quick-set paradigm,minime d,guardian test plug,minimed infusion,medtroni c remote BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 391 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value control,paradigm remote control,paradigm insulin pump,revel programmable pump,guardian rt charger,minilink real-time transmitter,suret,sure-t paradigm,mio infusion set,senserter,supreme,te na underwear,carefr ee pantiliners,bulkee ii,day & night brief,thermometer tip covers,urological catheter,active cath,3 step skin care,step 2moisture cream,step 3moisture barrier,step 1incontinent cleanser,ultrafresh,sleeve closure clamp,irrigation syringe,enema bag with catheter,mountin g ring,elastic belt,shut off for BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 392 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 5000 enema bag,lubriwipe,compact irrigator,colostokit irrigator,hospital pack irrigator,colostom y barium enema kit,female specimen catheter,tubing for irrigator,shut off for tubing,quick disconnectconnector,insertio n tube catheter,shield for insertion tube,travel case,laird tip,freedom t-tap leg bag kit,freedom leg bag,tube & connector kit,freedom twist port leg bag kit,colostotip,colo stotip w-quick disconnect,freedo m pak seven,freedom cath,response ii,touch ii,piston ii,economy pouch,mini-drain open end pouch,doubleBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 393 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value hesive,e-z hold,gizmo foam straps,uro-san plus,clear advantage,contin ent urinary catheter,colostop ads,cone tip,dermaguard,uro-san leg bag,plastic connector,deluxe leg bag straps,comfort leg bag straps,freedom drainage bag,gizmo,bandaid activ flex,seal tight,on call plus meter,on call plus control,on call plus lancing device,on call plus lancet,on call lancet,on call lancing device,on call vivid meter,on call vivid control,tens 502,tens 504,neurostimula tion electrodes,mask set,erapid nebulizer,erapid nebulizer handset,baby conversion BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 394 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value kit,vortex vhc ladybug mask,vortex vhc frog mask,sure comfort,poly hub needle,sure comfort lancets,sure comfort lancing pen,securely yours,quickables washcloths,ezsorb,attends,atte nds undergarments,at tends insert,attends underwear,attend s guards,tissuepak, attends light insert,attends booster,attends disposable underpads,gmate control solution,gmate voice starter,gmate voice meter,gluco navii,lancing system,choicedm clarus control soln,choicedm clarus,quintet,blo od glucose control,quintet ac,nasoneb nasal nebulizer,aeroecli BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 395 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value pse,aerochamber plus z stat,monaghan z stat,easy check control solution,easy step,easy plus,easy trak,easy talk,easy plus ii,maxicomfort,mini ultra-thin ii,mini lancing device,inject ease lancets,affirm underwear,affirm pads,snap pants,mesh pants,adult brief,prevail bladder control,cuties baby wipes,cuties wash cloths,prevail,was hcloths,prevail wet wipes,prevail premium washcloths,ameri can star washcloths,proca re washcloths,perso nal cloths,pant liner large plus,pant liner large,prevail BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 396 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value underwear,nu-fit brief,breezers,per -fit brief,value buy,prevail brief,prevail stretch fit,nufit underwear,prevai l simply stretch fit,prevail boxers,procare,pr evail full coverage undrwear,nufit brief,per-fit underwear,perfit brief,prevail perfit,ben-efit,prevail breezers,prevail extra underwear,prevai l bariatric,prevail super plus,prevail protective underwear,prevai l adjustable,prevail classic fit underwear,prevai l pm,prevail ultra plus,prevail ultra bladder,prevail panty liner,prevail extra plus bladder,prevail extra bladder,prevail guards for men,prevail BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 397 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value pads,prevail male guard,easy check,easy comfort,easy click,easy comfort insulin syringe,propylene glycol,easy touch lancets,toe straightener,up & up pantiliners,agiegrx,erase,erase ras-pouri,geridyne,hydrophor gauze,karaya gum,hydrocollgrx,calalgingrx,calalgin-grx rope,island gardgrx,grx hydrogel gauze,grx foam dressing,bloodglucose meter,profit,quick response,freestyl e insulinx,ultratlc lancets,medisens e control,precision glucose control,embrace glucose control soln,victory,advo cate control solution,advocate blood glucose monitor,advocate rapidBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 398 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value safe,advocate lancing device,advocate lancet,advocate redicode,advocate lancets,advocate redi-code duo,advocate duo,advocate redicode+,advocate redi-code+ ctrl soln,advocate syringes,advocat e pen needles,fabric bandages,neopre ne ankle support,neoprene knee stabilizer,neopren e knee support,neoprene wrist splint,new generation,sterile bandages,droppe r,ankle supportelastic,elbow supportelastic,wrist splint support,diabetic socks,pulmoneb lt compressor nebul,clever choice control solution,clever choice hd glucose BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 399 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value syst,clever choice blood gluc sys,clever chek blood glucose syst,clever chek lancets,clever choice pro,clever chek,clever choice,pharmacis t choice,clever choice micro,clever choice talk,comfort ez,fora d10,fora control solution,fora v10,fora v20,fora v22,fora g30a,fora g20,fora d15,fora d20,fora g90,fora lancing device,foracare lancets,freestyle system,freestyle sidekick ii,freestyle lancets,freestyle control solution,freestyle flash system,freestyle unistik 2,freestyle navigator,freestyl e lite meter,freestyle freedom,freestyle freedom BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 400 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value lite,freestyle precision,alcohwipe,alcohglove,t:slim,e.p.t, e.p.t digital,gmate,earl y pregnancy test,test n'go,cleo 90 infusion set,snap insulin pump-infusion set,snap insulin pump controller,dover universal,caresen sn voice,gentlecath, agamatrix amp,ezvac,natura drainable pouch,esteem synergy drainable pouch,sterile nitrile gloves,aquacelag extra,amber glass bottle,clear glass serum bottle,luer lock syringe,silverseal hydrogel,optumrx ,trueresult blood glucose meter,options liners,options pads,early ovulation test,options ultra BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 401 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value thins,little darlings,band-aid plus antibiotic,medlan ce plus special blade,easy touch fluringe,easy touch insulin safety,kangaroo 924 safety screw,easy touch syr allergy tray,easy touch fluringe flu tray,prevail curve,prevail smooth fit,excilon amd,element compact control soln,eakin cohesive,easy comfort pen needles,neria multi,element compact,depend shields for men,gmate lancing device,kendall disinfectant cap,huggies slipon,on-the-go,on call vivid pal,diatrue plus,diatrue,uroc are urinary drainage,uro-con catheter,eyelid cleansing pads,td BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 402 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value gold blood glucose monitor,td gold voice glucose monitor,td gold level 1 control sol,td gold level 2 control sol,td gold level 3 control sol,sheer bandage,rightest gc250s control soln,rightest gm250s meter,rightest gm260 meter,enlite glucose sensor,minimed 530g,smart sense monitoring system,relion thin,enlite serter,dexcom g5-g4 sensor,gentle touch system,gentle touch loop ostomy sys,tubigrip,tubul ar bandage applicator,tubipad ,lyofoam,lyofoam c,lyofoam a,lyofoam t,lyofoam extra,sur-fit natura post BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 403 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value op,eakin skin barrier,eakin fistula & wound pouch,pliagel,orth odiaphragm,advan ce pregnancy test,advanced care cholesterol test,opti-one,opticlean ii daily cleaner,opti-free lens case,nutriclamp w-transfer set,ascensia elite,omnitrope pen 5,personal biometric test kit,drainable adhesive pouch,baby urine collector,sharpsa-gator disposal system,insertion tray with pvp,excilon washcloth,curity maternity belts,curagel,nurs ing pads,dermicel,wa terproof tape,topper dressing sponge,surgipad, ulcer dressing,proxistrip,healthcare gloves,nu-gauze BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 404 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value sponge,elastikon, adaptic,sof-band bulky bandage,bioclusi ve,sof-wick,sofwick drain sponge,johnson & johnson filter mask,johnson's health care gloves,steripak,g auze sponge,rescue blanket,antiseptic wipes,triangular bandage,j & j first aid kit,swabs,cotton rounds,steripad,nugauze,dentotape ribbon floss,dental floss waxed,stim-udent,cartridge filling aid,arm belt,d-tron,h-tron power pack,autolet lite,back support,rib belt,pouch arm sling,wrist brace reversible,wrist brace splint,surgical binder abdom support,sacroiliac brace,herniaBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 405 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value aid,surgical stockings,compre ssion stockings,beyond support,super socks,compressi on pantyhose,athleti c supporter,cup supporter wprotector cup,suspensory,k nee comforter,curity curad flexible bandages,curity curad flexible fabric,curad ultralite,curad kid size bandages,curity underpads,bedpa n,sitz bath,urinal,cervic al pillow,cervical traction kit,wheelchair invalid ring,wheelchair cushion,crutch pad,walker tips,sport polartec,sport neoprene,tennis elbow support,curity curad adhesive bandages,curity telfa non-stick BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 406 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value pads,curity nursing pads,curity telfa adhesive pads,curity wetpruf adhesive tape,curad super soft puffs,curad gauze pads,curad stretch gauze bandage,fever thermometer,ace rubber elastic bandage,trutouch gloves,durall,sus pensory with leg straps,suspensor y w-o leg straps,adult supporter,compre ssion shorts,swimmer supporter,ace neoprene wrist brace,ace neoprene thigh brace,ace neoprene elbow brace,ace neoprene ankle brace,ace neoprene knee brace,ace neoprene plus knee brace,ace neoprene ankle wrap,ace tennis BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 407 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value elbow brace,ace ankle brace,ace knee brace,ace wrist brace,ace elastic bandage,ace elbow brace,ace plus rigid wrist brace,ace unibody supporter,ace athletic supporter,ace swim supporter,ace cup supporter,ace plus knee brace,ace sports underwrap,ace knee strap,ace elbow strap,ace bandage clips,ace athletic bandage,ace sports tape,ace instant cold compress,ace reusable cold compress,ace hot-cold compress,ace hot-cold compression wrap,ace velcro bandage,fever thermometerimprinted,sensica re,tru-fit knee BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 408 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value support,ace plastic gloves,sentinel thermometer,quic ktek,advance microdraw,advance,sel ect-lite,anti-stick insulin,anti-stick tuberculin,ventstr eam nebulizer,zoey,fir stchoice drainable pouch,everyday self-adhes catheter,firstchoic e postop drain pouch,selfadhesive catheter,advance hydro,seaband,sea-band for children,easypro, compressor nebulizer,replace ment nebulizer,replace ment air filter,healthy living,duocare,sharps disposal by mail,monoject blunt filter cannula,saline solution,sterile presrv,renu BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 409 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value saline,sensitive eyes enzymatic,lens carrying case,crayon bandage,easy read,sudacare advanced,pediac are gentle vapors,efferdent plus,efferdent,fre sh'n brite,effergrip,oha us scout sc,iv transfer needles,venting pin,ez-lets,insultote,dermagran,la dy lite,hard contact lens cleaner,hard contact lens soak,hard contact lens wet,kotex,kotex lightdays,new freedom lightdays,kotex new freedom,lil swimmer small pant,lil swimmer medium pant,lil swimmer large pant,poise,depen d belted shields,huggies overnite,huggies newborn,huggies convertibles,pelvi BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 410 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value c muscle trainer,babytherm pacifier thermometer,inco ntinent liner,dignity regular,dignity extra-duty,dignity regular duty,dignity natural extra,dignity diaper,dignity underpad,free & active super,dignity,dign ity plus,dignity plus liners,briefmates, prevent plus,dignity plus fitted brief,dignity plus regular brief,lady dignity plus brief,sir dignity plus brief,inhaler companions,asth ma control,interlink,w rist immobilizer,delux e wrist brace,ultra thin,water-proof bandages,plastic strip,heartstart,cli p& stor,fibracol,kling fluff,sofBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 411 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value kling,sheet protector,precisio n link,elta dermal,actis,rese rvoir,brief youth,promise pad,coverlet eye occlusor,real-time starter kit,ultrasoft plus,ultra-soft classic,protection plus underpad,protecti on plus,protection plus classic,home access hiv-1 test system,ultima tuckables,cairpad ,ultima incontinence,adh eres,tuffsorb,tuck ables,attends washcloths,preva il fits to a t,youth brief,adult frontal tape brief,prevail pre-moist bath cloth,pant liners,xtremefit brief,ultrathin,sto mahesive sterile wafer,sur-fit drainage container,sur-fit night drainage tubing,allkare adhesive remover wipe,active BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 412 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value life,little ones surfit ped belt,sur-fit tail closures,active life pouch,optipore,s etopress high compression,surfit natura irrig sleeve,flexiseal,active life one-piece,sur-fit natura visi-flow set,unna-flex plus,clerz-2 lubricatingrewetting,clerz2,mirasept,miras ept step 1,mirasept step 2,unisol 25 day pf saline,unisol plus,opti-one multipurpose,opticlean daily cleaner,preflex,sa line for sensitive eyes,alcon enzymatic,flexcare,opti-soak conditioning,optitears,opti-soak daily,opti-soak soothing drops,fact plus pregnancy test,primary pump set,nylon BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 413 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value epidural catheter,ls plum secondary setol,ivex-hp administration set,venoset-100 prim pigbk-ivexhp,screw cap set 38mm,fat emulsion iv set,primary iv setsl,soluset wpediatric ivex sl,venoset 100 piggyback wclamp,lifecare controller model 1000,lifecare pump set,lifecare model 4 macro pump,pca pump,nonvented iv set 100 with cair,venoset microdrip,lifecare 1025 controller,lc 1050 controller,flow detector 30inch,flow detector 54inch,lifecare pump,lifecare micro pump 1a,lifecare micro pump,controller lifecare model 75,pca plus 2,lifecare 75 flow BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 414 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value detector,solusetivex-2 filter & cair,dual i.v. stand adapter,i.v. stabilizer bar,i.v. clip adapter,i.v. stand-pole assembly,i.v. stand-base assembly,blood set 64 with cair clamp,blood set 78 with cair clamp,blood ytype set wpump,single shot epidurallidocaine,lifecare 1050 drop detector,enteral set with container,inpersol w-o auto shutoff valv,inpersol-auto shutoff valve,plumset speciality pump set-ol,plum lifecare 5000 infuser,site-care kit,ivex h.p. pediatric exten set,nonvented secondary iv set,venoset piggyback-mb pin-clmp,pca minibore,batteries, six BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 415 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value volt (pair),primary iv set-sl with ivexhp,500ml pressure infusion cuff,pressure infusion cuff,burette nv inline set wport,venoset dual-rate pgbkivex-2,cvc kit,venoset piggyback w-ivex filtr,lifecare shelf storage tray,primary piggyback nv ib set-sl,cvp manometer,drum -cartridge catheter,provider pump set,butterfly s.t. 19x7/8.31/2tbg,pca injector,flip-top additive cap,pump set wproximal male adapt,butterfly st,venous cannulation tray,blood set wcair clamp,tidal joint irrigation tray,cont epidural tray w-drugs,cont epidural-lido-epi t-dose,cont BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 416 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value epidural tray,spinal-22bupiv-dex-ephedepi,spinal-25bupiv-dex-ephedepi,spinalanesthesia tray,cont epidural-bupivlidocaine,inpersol peritoneal tray,caudal wlidocaineepinephrine,spina l-22-tet-ephedepi-iodine,nerve block tray wlidocaine,local infiltration wlidocaine,spinal25 w-tetra-ephedepi,saddle block anesthesia tray,saddleblock anesthesia tray,spinal-22 whitacre w-lidodext,spinal whitacre anesthesia,cont epidural w-poviodine,lumbar puncture adult,lifecare adds rack,primary piggybackconv,d ual injection site,male adapter BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 417 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value plug w-inj site,male luer cap,dual luer cap,plum lc 5000 primary setsl,plum microdrip soluset,extension set with luer lock,plum lc 5000 primary set,plum lc 5000 microdrip set-nv,plum lc 5000 with ivex,pca set-long minibore,venoset 100 soluset,pentothal dispensing cap,catheter adapter-luer plug,venoset nv piggybk micrdrp,crimping tool,transfer lok,blood set 64 w-cair & needle,hemoset 100x10 with cair clamp,blood set w-pump & cair clamp,blood surgical y-type set-clmp,blood ytype set 66-cair clamp,continuous pediatric caudal,cont epidural w-lidoepi-iodin,lifecare BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 418 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value microdrip pump set,nitroglycerin micro pump set,screw cap (40mm) set,lifecare 5000 syringe adapter,lifecare 5000 vial adapter,hema blood 30 set,bufpuf,buf-puf bodymate,buf-puf sponge,buf-puf gentle,microlet vaculance,accus ure,opti-zyme enzymatic cleaner,bard irrigation tray,3m cold-hot pack,home care underpads,takeoff,conform stretch bandage,coets,d ermilite-ii paper tape,dermicel hypo-allergenic tape,dermilite ii hypoallergenic,dermicl ear,kling bandage,waterga rd,insertion tray with bzk,foley cath silicone retn,curity foley 2-way ped BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 419 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value cath,folding walker,walker wheels,cervical soft collar,molicare classic brief,ultra soft,dry time diaper,protection plus liner,economy underpad,peg elastic bandage,reston2,iamin,osmocyte ,dressing,digital therm probe cover,hypotherm thermometer,bd genie lancet,ace wrist brace with splint,ace lumbar support,statlet,disgard sharps pad,kangaroo 1000ml pump set,glucoleader,le a's shield,saline solution, unpreserved,hyp o-clear,lens lubricant,disinfect ing solution,quiksept,renu weekly cleaner,concentr ated cleaner,wetting & soaking solution,super denture BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 420 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value adhesive,disinfec ting unit,compact disinfecting unit,fashion case,lens cup,snug denture cushions,thermod ent,contact lens conditioning,niteti me,interdental stimulators,extra absorbent shield,wild hot strips,napkin hospital tabbed,foot and shoe padding,bed pad,sudacare,chil dren's sudacare,rgp wetting and soaking,rigid gas permeable cleaner,lubricatin g drops,htronplus adapter,h-tron plus-piston rod,htron plus,catheter tip cap,winged,chem oplus dispensing pin,p2 hi-risk,p2 safety plus,p2 safety plus powder free,p2 hi-risk powder free,pro star BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 421 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value powder free,oncology plus,chemoplus powder free,chemoplus,d ust-mist respirator mask,chemosafet y container,u.v. protection bags,spill proof prep mat,safelock bags,chemowast e bags,chemolinen waste bags,chemolinen hamper stand,chemowast e hamper stand,chemosafet y prep admin,personnel protection,multimix,designer,che mo plus,chemo spill kit,trudent,wetstop,dermastat,n utrastat,dermacol ,nutracol,dermasi te,sanitizer bottle,autolancet,sensitive teeth,tartar control,depend elastic leg undergarmnt,dep end fitted BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 422 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value brief,goodnite,hu ggies snuggems,huggie s convertible clip strip,huggies supreme,first choice thin lancets,slipon,entrust plus undergarment,br east pump,nebulizer,fil ters,mask,sphyg momanometer,ad apter w-disp mouthpiece,mout hpiece for truzone peak fl,mask, pediatric,proneb, pep pressure monitor,bubbles the fish,pep nebulizer,lc nebulizer,nite train'r,empty viaflex-y-transfer set,sub-q set,empty viaflex container,bed underpads,contro l pads,clear spots,7 day pill box,fancy pill box,pill pal,one weektoday,rubber finger,dosage spoon,dosage BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 423 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value syringe,dosage dropper,hot & cold wrap,super absorbent underwear,ultrathin underwear,polyrayon,3m paper pre-cut tape strips,clear first aid tape,active strips,waterproof adhesive,foam sports tape,3m non-stick pads,heat comfort,e.p.t. stick test,barrier sterile field,biopatch,nubrede,topper,tiell e,bioclusive select,bioclusive select mvp,bioclusive mvp select,nu-gel collagen,algosteri l,nu-gel,raytec,soffoam,band-aid island surgical,zonas,de rmiview,dermifor m,tielle plus,kling conforming gauze bandage,dynaflex,ultralon pf,maxxus BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 424 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value pf,micro-touch pf,allergard,neutr alon 50,maxxus,neutr alon,microtouch,microtouch xp,sofloop,surgine,barri er,surgine ii,barrier n95,protectivw,protectiv plusw,biovue,protecti v,lister's suture removal kit,barrier fenestrated strl field,preptic shave prep,preptic 2 shave prep,chix,sofnet,d aylee,preptic,prevac are,autolancet device wlancets,ultratlc lancetsdevice,pocketcar e irrigator,e-z spacer mask,e-z spacer & mask,supreme glucose control,supreme meter,simplechoi ce,simplechoice quick,md turbo,aerochamb BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 425 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value er plus,airs pediatric aerosol mask,continuous glucose sensor,evacare pessary,relion blood pressure cuff,muppet strips,cleaning solution,wetting solution for hard lens,nonpreserved saline,oragrip,ho me pregnancy test,absorbent shield,poison first aid kit,facial cleansing sponge,pill divider,shave cream,blade double edge,lady's shaver plus lube strip,weekly pill planner,effervesc ent denture cleansr,effervesc ent denture,premier adult brief,safe klean,one-step blood pressure monitr,precision sof-tact,precision q-i-d,dental floss unwaxed,mercury klean BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 426 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value kit,enlite,well beginnings diapers,novopen echo,filtered extension set,rate flow regulator iv set,aerobika,accu -chek compact plus control,soothene b mesh nebulizer,onetouc h verio sync,unistrip,iport advance,hydrofer a blue,foracare gdh,acticoat site,acticoat moisture control,acticoat flex 7,acticoat flex 3,allevyn life,embrace pro,embrace evo,kendall foam border,luer slip tip cap,luer-lock syringe,amber oral-topical syringe,slip-tip syringe,caresens prem lancing device,carelance ult lancing device,acticoat surgical,luer slip tip syringe tray,md pump BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 427 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value actuator b,md pump actuator a,on call express meter,on call express control soln,athletic tape,healthpro glucose monitor,healthpro glucose control soln,md pump bottle airless,md pen airless,md syringe airless,md jar airless,biostep ag,space chamber plus,compact space chamber plus,ems antiembolism stocking,allevyn adhesive,biostep, allevyn sacrum,allevyn ag adhesive,icy hot smart relief tens,icy hot smart relief tens pads,ear-loop mask,temple touch mini thermometer,pur ple nitrile gloves,allevyn ag gentle,allevyn ag,prevail breezers BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 428 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 360,allevyn gentle border,temple touch prem thermometer,adv anced glucose meter,allevyn gentle border lite,carefine pen needle,allevyn gentle border sacrum,allevyn gentle border heel,allevyn gentle border multisit,microbore extension set,prevail per-fit 360,clear tape,transparent film dressing,gmate smart starter,gmate smart meter,true metrix blood glucose mtr,true metrix,vascuderm hydrogel wound,huggies pure & natural,varithena administration pack,band-aid gauze pads,band-aid rolled gauze,band-aid non-stick BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 429 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value pads,band-aid mirasorb gauze sponge,band-aid surgipad dressing,bandaid cloth tape,band-aid paper tape,bandaid waterproof tape,sterile amber glass vial,aeroneb go,slip on knee,band-aid hurt-free,bandaid tough pads,band-aid secureflex,innospire deluxe,band-aid waterproof pad,innospire mini,novofine plus,fora test n'go voice,cuticerin,m egapumpblue,fora gd50,primer modified unna boot,fortiscare blood glucose syst,fortiscare,tel care bgm,nighttime underpants,allevy n tracheostomy,cuti nova hydro,durafiber,re BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 430 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value plicare thin,allevyn thin,surgical pads,iv3000 frame delivery,md pump actuator c,bardex lubricath foley,inspiracham ber,mepitel,aeron eb go nebulizer,lanzo,al gicell ag,bioguard gauze,bioguard packing,bioguard nonadherent,bioguar d island,fc2 female condom,hydress, aquacel ag foam,element compact v,fora test n'go bp,aquacel ag foam heel,aquacel ag foam sacral,aquacel foam sacral,devilbiss pulmoneb lt compneb,prodigy autocode,assure prism multi,glucocard shine,assure lance BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 431 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value plus,esteem synergy+,sterile droptainers,assur e prism,animas vibe,sensi-care adhes remover wipes,relief knee open toe,apogee hc intermittent,unisti k safety,true metrix air glucose meter,hydrofera blue ready,push button safety lancets,t:flex,well beginnings training pants,caya contoured,estee m+ durahesive plus,esteem+ drainable pouch,urocare fabric leg straps,drymax extra,pentips,acc u-chek aviva connect,thumb support,tegaderm hydrogel,flexicha mber,goodnites tru-fit,medihoney hcs,dermagran hydrophilic wound,cool mist humidifier,mistas sist kit,humatropen,m BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 432 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value istassist,dexcom g5,fora v10-v12d10d20,evencare mini monitor system,evencare mini glucose control,tens replacement back pads,tens replacement body pads,luer tip cap tray,t:90,t:slim g4,dry time training pants,bioguard conforming,jobst anti-embolism stocking,jobst ultrasheer,fora tn'g voice,capri bladder control pads,prevail purseready,oneto uch verio flex,fora lancets,droplet pen needle,blood lancets,easy touch unislip,easy touch fliplock syringes,aerovent plus,linktemp,free style precision neo meter,fora d40,easy touch fliplock needle,easy BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 433 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value touch fliplock needles,easy touch fliplock syringe,vacustim black,tegaderm + pad,advanced healing bandage,advanc ed healing pad,easy touch sheathlock syringe,easy touch hypodermic needle,easy touch luer lock syringe,topcare universal1 lancet,multilancet,cool blood glucose meter 03/01/2016 auviepinephrine q,adrenaclick,epi nephrine REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 434 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 aspirin,aspirin aspirin ec,ecotrin,childre n's aspirin,low dose aspirin ec,st joseph aspirin,aspirlow,stanback analgesic,aspirtrin,bayer chewable aspirin,bayer advanced,asperd rink,lite coat aspirin,lo-dose aspirin ec,acetyl salicylic acid,adult low dose aspirin ec,miniprin,zorpri n,halfprin,baby aspirin,aspir 81,ecpirin,st. joseph aspirin,easprin,ad ult low strength aspirin,genacote, pain reliver super strength,adult low strength,bayer aspirin,bayer extra strength,aspirina, analgesic,aspirin sr,durlaza REMOVE UM: CUSTOM 03/01/2016 QVAR beclomethasone dipropionate REMOVE UM: CUSTOM Cumulative: MED 200mg/day 03/01/2016 codeine sulfate codeine sulfate REMOVE UM: CUSTOM Cumulative: MED 200mg/day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 435 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2016 codeine sulfate codeine sulfate REMOVE UM: CUSTOM Cumulative: MED 200mg/day 03/01/2016 codeine sulfate codeine sulfate REMOVE UM: CUSTOM Cumulative: MED 200mg/day 03/01/2016 ULORIC febuxostat REMOVE UM: CUSTOM Cumulative: MED 200mg/day 03/01/2016 trilipix,fenofibric acid fenofibric acid (choline) REMOVE UM: CUSTOM 03/01/2016 ipratropiumipratropium albuterol,combive bromide/albuterol sulfate nt,combivent respimat,duoneb REMOVE UM: CUSTOM 03/01/2016 hyzaar,losartan- losartan hydrochlorothiazi potassium/hydrochlorothiazi de de REMOVE UM: CUSTOM 03/01/2016 HYZAAR 03/01/2016 oxybutynin oxybutynin chloride chloride er,oxybutynin chloride,ditropan xl,gelnique,ditrop an losartan potassium/hydrochlorothiazi de REMOVE UM: QUANTITY 1 / Day REMOVE UM: CUSTOM BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 436 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value 03/01/2016 lactocal-f,o-cal prenatal vitamins with fa,vynatalcalcium/ferrous fa,prenatal fumarate/folic acid vitamins,prenatal, natalvit,mynatal, mynatalz,mynatal plus,prenatal plus,prenafirst,stu art prenatal,prenatal formula,right step prenatal vitamins REMOVE UM: CUSTOM 03/01/2016 maxalt,maxalt mlt,rizatriptan REMOVE UM: CUSTOM 03/01/2016 butalbital-aspirin- butalbital/aspirin/caffeine caffeine,butalbital compound,fiorinal ,farbital REMOVE UM: CUSTOM Cumulative: 4gm/day acetaminophen 03/01/2016 NUVARING REMOVE UM: CUSTOM Cumulative: 4gm/day acetaminophen 03/01/2016 copaxone,glatopa glatiramer acetate REMOVE UM: CUSTOM 03/01/2016 REBIF,REBIF interferon beta-1a/albumin REBIDOSE,AVO human NEX REMOVE UM: CUSTOM 03/01/2016 amnesteem,clara isotretinoin vis,absorica,sotre t,zenatane,myoris an,accutane,isotr etinoin REMOVE UM: CUSTOM 03/01/2016 REVLIMID lenalidomide REMOVE UM: CUSTOM 03/01/2016 midodrine hcl,proamatine midodrine hcl REMOVE UM: CUSTOM rizatriptan benzoate etonogestrel/ethinyl estradiol New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 437 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value 03/01/2016 naratriptan naratriptan hcl hcl,amerge,naratr iptan CHANGE UM: CUSTOM 03/01/2016 TAMIFLU REMOVE UM: CUSTOM 03/01/2016 triveenprenatal vits without calc u,prenatal-u,pnv- no5/ferrous fumarate/folic vp-u acid REMOVE UM: CUSTOM 03/01/2016 aldactazide,spiro spironolactone/hydrochlorot nolactone-hctz hiazide REMOVE UM: CUSTOM 03/01/2016 sumatriptan succinate sumatriptan succinate REMOVE UM: CUSTOM Cumulative: 4gm/day acetaminophen 03/01/2016 IMITREX sumatriptan succinate REMOVE UM: CUSTOM Cumulative: 4gm/day acetaminophen 03/01/2016 aralen chloroquine phosphate phosphate,chloro quine phosphate REMOVE UM: CUSTOM 03/01/2016 chlorpropamide,d chlorpropamide iabinese REMOVE UM: CUSTOM 03/01/2016 glynase,glyburide glyburide,micronized micronized REMOVE UM: CUSTOM 03/01/2016 prinzide,lisinopril- lisinopril/hydrochlorothiazide hydrochlorothiazi de,zestoretic,lisin opril-hctz REMOVE UM: CUSTOM oseltamivir phosphate New Value Cumulative: 9 tabs per 30 days across oral statins Cumulative: 4gm/day acetaminophen BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 438 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change 03/01/2016 thrive nicotine polacrilex nicotine,nicotine gum,nicotine lozenge,nicorette, commit,nicorelief, stop smoking aid,nicotine polacrilex,quit 2,quit 4 REMOVE UM: CUSTOM 03/01/2016 pramipexole pramipexole di-hcl dihydrochloride,m irapex,mirapex er,pramipexole er REMOVE UM: CUSTOM 03/01/2016 terazosin hcl,hytrin REMOVE UM: CUSTOM 03/01/2016 beconase beclomethasone aq,beclomethaso dipropionate ne dipropionate,qvar ,qnasl,qnasl children REMOVE UM: CUSTOM 03/01/2016 zelapar,selegiline selegiline hcl hcl,eldepryl REMOVE UM: CUSTOM 03/01/2016 pioglitazone hcl,actos REMOVE UM: CUSTOM terazosin hcl pioglitazone hcl Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 439 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change 03/01/2016 vicodin,vicodin hydrocodone es,vicodin bitartrate/acetaminophen hp,zolvit,hydroco doneacetaminophen,c ogesic,hydrogesic, lorcet plus,lorcet 10650,hycet,lortab,x odol 10300,xodol 5300,xodol 7.5300,norco,maxid one,zydone,stage sic,zamicet,lorcet ,lorcet hd,verdrocet REMOVE UM: CUSTOM 03/01/2016 amilorideamiloride hydrochlorothiazi hcl/hydrochlorothiazide de,amiloride hclhctz REMOVE UM: CUSTOM 03/01/2016 dipyridamole,pers dipyridamole antine REMOVE UM: CUSTOM 03/01/2016 imiquimod,aldara, imiquimod zyclara REMOVE UM: CUSTOM 03/01/2016 peg-3350 with sodium chloride/sodium flavor bicarbonate/potassium packs,gavilytechloride/peg n,nulytely with flavor packs,nulytely,tril yte with flavor packets,peg 3350-electrolyte REMOVE UM: CUSTOM Previous Value New Value Cumulative: 4gm/day acetaminophen Cumulative: 2 syringes/30 days across inj triptans BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 440 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value 03/01/2016 ZORTRESS,AFI everolimus NITOR,AFINITO R DISPERZ REMOVE UM: CUSTOM 03/01/2016 accupril,quinapril quinapril hcl hcl REMOVE UM: CUSTOM 03/01/2016 CHANTIX CHANGE UM: CUSTOM 03/01/2016 amantadine,ama amantadine hcl ntadine hcl 03/04/2016 COPAXONE glatiramer acetate REMOVE FROM FORMULARY Covered 03/04/2016 COPAXONE glatiramer acetate REMOVE UM: AUTHORIZATION PA applies 03/04/2016 COPAXONE glatiramer acetate REMOVE UM: QUANTITY 1 / Day 03/04/2016 glatopa glatiramer acetate REMOVE UM: AUTHORIZATION 03/04/2016 SANTYL collagenase clostridium histolyticum REMOVE UM: AUTHORIZATION varenicline tartrate New Value Max 24 weeks therapy per year REMOVE UM: CUSTOM Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 441 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date 03/07/2016 Brand Name Generic Name novofine pen needle, diabetic 32,novofine,novot wist,unifine pentips,pen needle,incontrol pen needle,pen needles,unifine pentips plus,healthy accents unifine pentip,ulticare pen needle,insupen,in sulin pen needle,bd ultrafine pen needle,ultilet pen needle,clickfine,r elion pen needles,ultracomf ort,prodigy pen needle,easy touch pen needle,1st tier unifine pentips,1st tier unifine pentips plus,lite touch,needles,top care clickfine,sure-fine pen needles,sure comfort,ultra-thin ii,mini ultra-thin ii,advocate pen needles,comfort ez,easy comfort pen needles,carefine Type of Change Previous Value CHANGE TIER New Value Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 442 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value pen needle,novofine plus,pentips,dropl et pen needle,techlite pen needle 03/07/2016 amoxicillin 03/07/2016 amoxicillin CHANGE TIER Covered cipro,ciprofloxaci ciprofloxacin hcl n hcl CHANGE TIER Covered 03/07/2016 ciprofloxacin hcl,cipro CHANGE TIER Covered 03/15/2016 HUMIRA,HUMIR adalimumab A PEN,HUMIRA PEN CROHNUC-HS STARTER,HUMI RA PEN PSORIASISUVEITIS,HUMIR A PEDIATRIC CROHN'S 03/18/2016 budesonide budesonide CHANGE TIER 03/18/2016 PULMICORT budesonide REMOVE UM: QUANTITY 2 / Day 03/18/2016 PLAN B ONESTEP levonorgestrel REMOVE FROM FORMULARY Covered 03/18/2016 PLAN B ONESTEP levonorgestrel REMOVE UM: GENDER Female 03/18/2016 memantine hcl memantine hcl ADD TO FORMULARY Covered 03/18/2016 memantine hcl memantine hcl ADD UM: AUTHORIZATION PA applies 03/18/2016 memantine hcl memantine hcl ADD UM: QUANTITY 49 / 1 years 03/18/2016 TANZEUM albiglutide ADD TO FORMULARY Covered ciprofloxacin hcl REMOVE UM: AUTHORIZATION Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 443 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/18/2016 TANZEUM albiglutide ADD UM: AUTHORIZATION PA applies 03/18/2016 TANZEUM albiglutide ADD UM: QUANTITY 4 / 28 days 03/18/2016 TANZEUM albiglutide ADD UM: QUANTITY 4 / 28 days 03/18/2016 MARTEN-TAB butalbital/acetaminophen 03/18/2016 REMOVE FROM FORMULARY Covered Non-Formulary amnesteem,clara isotretinoin vis,absorica,zena tane,myorisan,sot ret,accutane CHANGE UM: QUANTITY 1 / Day 2 / 1 days 03/18/2016 amnesteem,clara isotretinoin vis,absorica,sotre t,zenatane,myoris an,accutane CHANGE UM: QUANTITY 1 / Day 2 / 1 days 03/18/2016 sumatriptan succinate sumatriptan succinate CHANGE UM: QUANTITY 0.3 / day 9 / 30 days 03/18/2016 sumatriptan succinate sumatriptan succinate CHANGE UM: QUANTITY 0.3 / day 9 / 30 days 03/18/2016 sumatriptan succinate sumatriptan succinate ADD UM: CUSTOM 03/18/2016 sumatriptan succinate sumatriptan succinate CHANGE UM: QUANTITY 03/18/2016 sumatriptan succinate sumatriptan succinate ADD UM: CUSTOM Cumulative across per all oral doses 03/18/2016 sumatriptan succinate sumatriptan succinate ADD UM: CUSTOM Cumulative across all oral doses 03/18/2016 ondansetron hcl ondansetron hcl CHANGE UM: QUANTITY 3 / 1 days 03/18/2016 ondansetron hcl ondansetron hcl CHANGE UM: QUANTITY 3 / 1 days 03/18/2016 ondansetron hcl ondansetron hcl CHANGE UM: QUANTITY Cumulative across all oral doses 0.3 / day 0.3 / day 9 / 30 days 1 / 1 days BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 444 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/18/2016 ondansetron odt ondansetron CHANGE UM: QUANTITY 0.6 / day 3 / 1 days 03/18/2016 ondansetron odt ondansetron CHANGE UM: QUANTITY 0.8 / day 3 / 1 days 03/18/2016 sumatriptan succinate sumatriptan succinate CHANGE UM: QUANTITY 1 / month 4 / 30 days 03/18/2016 sumatriptan succinate sumatriptan succinate CHANGE UM: QUANTITY 1 / month 4 / 30 days 03/18/2016 sumatriptan succinate sumatriptan succinate CHANGE UM: QUANTITY 1 / month 4 / 30 days 03/18/2016 sumatriptan succinate sumatriptan succinate CHANGE UM: QUANTITY 1 / month 4 / 30 days 03/18/2016 sumatriptan succinate sumatriptan succinate CHANGE UM: QUANTITY 1 / month 4 / 30 days 03/18/2016 IMITREX sumatriptan succinate REMOVE UM: AUTHORIZATION PA applies 03/18/2016 IMITREX sumatriptan succinate REMOVE UM: QUANTITY 1 / month 03/18/2016 IMITREX sumatriptan succinate REMOVE UM: QUANTITY 1 / month 03/18/2016 ZYVOX linezolid 03/18/2016 TAMIFLU 03/18/2016 ADD UM: QUANTITY 20 / rx oseltamivir phosphate ADD UM: CUSTOM Max 40 per 180 days TAMIFLU oseltamivir phosphate ADD UM: CUSTOM Max 20 per 180 days 03/18/2016 zyvox,linezolid linezolid CHANGE UM: AUTHORIZATION PA applies 03/18/2016 zyvox,linezolid linezolid REMOVE UM: QUANTITY 03/18/2016 TAMIFLU oseltamivir phosphate ADD UM: QUANTITY 10 / rx 03/18/2016 TAMIFLU oseltamivir phosphate ADD UM: CUSTOM Max 20 per 180 days 03/18/2016 TAMIFLU oseltamivir phosphate ADD UM: QUANTITY 60 / rx BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 445 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/18/2016 TAMIFLU oseltamivir phosphate ADD UM: CUSTOM Max 120 per 180 days 03/18/2016 TAMIFLU oseltamivir phosphate REMOVE UM: AGEQUANTITY 03/28/2016 NEXIUM 24HR esomeprazole magnesium ADD TO FORMULARY Covered 03/28/2016 NEXIUM 24HR esomeprazole magnesium ADD UM: QUANTITY 60 / 30 days 03/28/2016 glipizide er,glipizide xl glipizide CHANGE TIER Covered 03/28/2016 MENEST estrogens,esterified ADD TO FORMULARY Non-Formulary Covered 03/28/2016 MENEST estrogens,esterified ADD TO FORMULARY Non-Formulary Covered 03/28/2016 MENEST estrogens,esterified ADD TO FORMULARY Non-Formulary Covered 03/28/2016 MENEST estrogens,esterified ADD TO FORMULARY Non-Formulary Covered 03/28/2016 APRISO mesalamine ADD TO FORMULARY Covered 03/28/2016 linezolid linezolid ADD TO FORMULARY Covered 03/28/2016 epinephrine epinephrine ADD TO FORMULARY Non-Formulary Covered 03/28/2016 epinephrine epinephrine CHANGE UM: QUANTITY 0.02 / day 0.6 / 30 Days 03/28/2016 naproxen sodium naproxen sodium ADD TO FORMULARY 03/28/2016 naproxen sodium naproxen sodium ADD TO FORMULARY 03/28/2016 betamethasone dipropionate betamethasone dipropionate/propylene glycol ADD TO FORMULARY Covered 03/28/2016 halobetasol propionate halobetasol propionate ADD TO FORMULARY Covered 03/28/2016 halobetasol propionate halobetasol propionate ADD TO FORMULARY Covered 03/28/2016 hydrocodoneacetaminophen hydrocodone bitartrate/acetaminophen ADD UM: QUANTITY 1800 / 30 Days Up to 12 yrs old; 25 / day Covered Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 446 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name 03/28/2016 hydrocodoneacetaminophen hydrocodone bitartrate/acetaminophen 03/28/2016 betamethasone dipropionate 03/28/2016 Type of Change Previous Value New Value ADD UM: CUSTOM Max of 4000MG of Apap/day betamethasone dipropionate/propylene glycol ADD TO FORMULARY Covered betamethasone dipropionate betamethasone dipropionate/propylene glycol ADD TO FORMULARY Covered 03/28/2016 betamethasone dipropionate betamethasone dipropionate ADD TO FORMULARY Covered 03/28/2016 PHOSPHOLINE IODIDE echothiophate iodide ADD TO FORMULARY 03/28/2016 SUPRAX cefixime ADD TO FORMULARY Covered 03/28/2016 cefixime cefixime ADD TO FORMULARY Covered 03/28/2016 FML FORTE fluorometholone CHANGE UM: QUANTITY 0.333 / day 10 / 30 Days 03/28/2016 FML FORTE fluorometholone ADD TO FORMULARY Non-Formulary Covered 03/28/2016 SUPRAX cefixime ADD TO FORMULARY Covered 03/28/2016 metoclopramide hcl metoclopramide hcl ADD TO FORMULARY Covered 03/28/2016 PRESERVISION vit c/vit e acetate/zn AREDS 2 oxide/cupric oxide/lutein/zeaxanthin ADD TO FORMULARY 03/28/2016 TANZEUM albiglutide ADD TO FORMULARY 03/28/2016 TANZEUM albiglutide CHANGE UM: QUANTITY 03/28/2016 tolterodine tartrate tolterodine tartrate ADD TO FORMULARY 03/28/2016 tolterodine tartrate tolterodine tartrate CHANGE UM: QUANTITY Non-Formulary Non-Formulary Covered Covered Covered 4 / 28 days 4 / 28 Days Covered 2 / Day 60 / 30 Days BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 447 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/28/2016 fluticasone propionate fluticasone propionate ADD TO FORMULARY Covered 03/28/2016 24 hour allergy relief fluticasone propionate ADD TO FORMULARY Covered 03/28/2016 CHILDREN'S FLONASE ALLERGY RLF fluticasone propionate ADD TO FORMULARY Covered 03/28/2016 all day pain relief naproxen sodium CHANGE UM: QUANTITY 3 / Day 180 / 30 Days 03/28/2016 all day pain relief naproxen sodium ADD TO FORMULARY Non-Formulary Covered 03/28/2016 naproxen sodium naproxen sodium ADD TO FORMULARY 03/28/2016 naproxen sodium naproxen sodium ADD TO FORMULARY 03/28/2016 naproxen sodium naproxen sodium ADD UM: QUANTITY 03/28/2016 naproxen sodium naproxen sodium CHANGE UM: QUANTITY 03/28/2016 ALL DAY RELIEF naproxen sodium ADD UM: QUANTITY 03/28/2016 all day relief,naproxen sodium,all day pain relief 03/28/2016 ALL DAY RELIEF naproxen sodium ADD TO FORMULARY 03/28/2016 all day relief,naproxen sodium,all day pain relief naproxen sodium ADD TO FORMULARY Non-Formulary Covered 03/28/2016 wal-proxen naproxen sodium ADD TO FORMULARY Non-Formulary Covered 03/28/2016 wal-proxen naproxen sodium CHANGE UM: QUANTITY 3 / Day 180 / 30 Days 03/28/2016 flanax naproxen sodium ADD TO FORMULARY Non-Formulary Covered 03/28/2016 flanax naproxen sodium CHANGE UM: QUANTITY 3 / Day 180 / 30 Days 03/28/2016 mediproxen naproxen sodium ADD TO FORMULARY Non-Formulary Covered naproxen sodium CHANGE UM: QUANTITY Covered Non-Formulary Covered 180 / 30 Days 3 / Day 180 / 30 Days 180 / 30 Days 3 / Day 180 / 30 Days Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 448 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name naproxen sodium Type of Change Previous Value New Value CHANGE UM: QUANTITY 3 / Day 180 / 30 Days 03/28/2016 mediproxen 03/28/2016 naproxen sodium naproxen sodium cr,naproxen sodium er ADD TO FORMULARY Non-Formulary Covered 03/28/2016 NAPRELAN naproxen sodium ADD TO FORMULARY Non-Formulary Covered 03/28/2016 cefixime cefixime ADD TO FORMULARY 03/28/2016 COPEGUS ribavirin REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 PEGASYS PROCLICK peginterferon alfa-2a REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 PEGASYS PROCLICK peginterferon alfa-2a REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 DEPOPROVERA medroxyprogesterone acetate REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 moderiba ribavirin REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 PEGINTRON peginterferon alfa-2b REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 PEGINTRON peginterferon alfa-2b REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 PEGINTRON REDIPEN peginterferon alfa-2b REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 PEGINTRON peginterferon alfa-2b REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 PEGINTRON REDIPEN peginterferon alfa-2b REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 PEGINTRON REDIPEN peginterferon alfa-2b REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 PEGINTRON peginterferon alfa-2b REMOVE FROM FORMULARY Covered Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 449 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/28/2016 PEGINTRON REDIPEN peginterferon alfa-2b REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 ribavirin ribavirin REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 ribavirin ribavirin REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 lidocaineprilocaine lidocaine/prilocaine REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 ENTOCORT EC budesonide REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 diltiazem 24hr diltiazem hcl er,diltiazem 24hr cd REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 budesonide ec budesonide REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 multi-vitamin wfluoride,multivita mins with fluoride,polyvitam ins-fluoride pediatric multivitamin combination no.2/sodium fluoride,pediatric multivitamins no.82 with sodium fluoride REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 multi-vitamin wfluoride,multivita min and fluoride,multivita mins with fluoride pediatric multivitamin combination no.2/sodium fluoride,pediatric multivitamins no.82 with sodium fluoride REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 multi-vitaminfluoriron,multivitamins w-fluorideiron,multi-vitamin w-fluoride-iron pediatric multivitamin combo no.45/fluoride/ferrous sulfate,pediatric multivitamin combo no.75/fluoride/ferrous sulfate REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 loperamide loperamide hcl REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 450 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/28/2016 FLULAVAL 2013- influenza virus vaccine tvs 2014 2013-2014 (36 mos and older) REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 FLULAVAL QUAD 20142015 influenza virus vaccine quad vs 2014-2015 (36 mos & older) REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 FLULAVAL 2014- influenza virus vaccine trival 2015 2014-15 (36 mos and older)/pf REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 FLULAVAL 2014- influenza virus vaccine 2015 trivalent 2014-15 (36 mos and older) REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 FLULAVAL QUAD 20142015 influenza virus vaccine quadrival 2014-15(36 mos & older)/pf REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 FLULAVAL QUAD 20132014 influenza virus vaccine quad vs 2013-2014 (36 mos & older) REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 AFLURIA 20132014 influenza virus vaccine tv split 2013-2014 (5 yr & older)/pf REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 AFLURIA 20142015 influenza virus vaccine trivalnt 2014-2015 (5 yr & older)/pf REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 AFLURIA 20132014 influenza virus vaccine tv split 2013-2014 (5 yr & older) REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 AFLURIA 20142015 influenza virus vaccine trivalent 2014-2015 (5 yr & older) REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 451 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/28/2016 prenatal formula prenatal vits with calcium #95/ferrous fumarate/folic acid,prenatal vitamin with ca no.131/ferrous fumarate/folic acid,prenatal vitamins with calcium/ferrous fumarate/folic acid REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 prenatal vitamin prenatal vitamin with ca no.128/ferrous fumarate/folic acid REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 FLUBLOK 2013- influenza virus vaccine tv 2014 2013-2014 (18 to 49 yrs)recomb/pf REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 FLUBLOK 2014- influenza virus vaccine tv 2015 2014-2015(18 yrs & older)rcmb/pf REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 multivitamins with pediatric multivitamins fluoride,multivita combination no.12/sodium min with fluoride fluoride,multivitamins with fluoride,pediatric multivitamins no.16 with sodium fluoride,pediatric multivitamins no.17 with sodium fluoride REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 multivitamin with pediatric multivitamins no.17 fluoride with sodium fluoride,pediatric multivitamins combination no.12/sodium fluoride REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 selenium sulfide REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 FLUZONE 2013- influenza virus vaccine tvs 2014 2013-2014 (36 mos and older)/pf REMOVE FROM FORMULARY Covered Non-Formulary selenium sulfide BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 452 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/28/2016 FLUZONE 2013- influenza virus vaccine tvs 2014 2013-2014 (36 mos and older)/pf REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 FLUZONE 2014- influenza virus vaccine trival 2015 2014-15 (36 mos and older)/pf REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 FLUZONE PEDI 2013-2014 influenza virus vaccine tvs 2013-2014 (6 mos-35 mos)/pf REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 FLUZONE 2013- influenza virus vaccine tri2014 split 2013-14 (6 mos and older) REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 FLUZONE HIGH- influenza virus vaccine tvs DOSE 2013-2014 2013-2014 (65 yr+)/pf REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 FLUZONE 2014- influenza virus vaccine 2015 trivalent 2014-15 (6 mos and older) REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 FLUZONE HIGH- influenza virus vaccine DOSE 2014-2015 trivalent 2014-2015 (65 yr+)/pf REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 FLUZONE QUAD influenza virus vaccine quad 2013-2014 vs 2013-2014(36 mos & older)/pf REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 FLUZONE QUAD influenza virus vaccine quad 2013-2014 vs 2013-2014(36 mos & older)/pf REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 FLUZONE QUAD influenza virus vaccine 2014-2015 quadrival 2014-15(36 mos & older)/pf REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 FLUZONE QUAD influenza virus vaccine 2014-2015 quadrival 2014-15(36 mos & older)/pf REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 453 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/28/2016 FLUZONE QUAD influenza virus vaccine quad PEDI 2013-2014 vs 2013-2014 (6 mos-35 mos)/pf REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 FLUZONE QUAD influenza virus vaccine PEDI 2014-2015 quadrival 2014-15 (6 mos35 mos)/pf REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 FLUZONE QUAD influenza virus vaccine 2014-2015 quadrival 2014-2015 (6 mos & older) REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 FLUZONE INTRADERMAL 2013-2014 influenza virus vaccine tvs 2013-2014 (18 yrs-64 yrs)/pf REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 FLUZONE INTRADERMAL 2014-2015 influenza virus vaccine trivalent 2014-15 (18 yrs-64 yrs)/pf REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 FLUVIRIN 2013- influenza virus vaccine tv 2014 split 2013-2014 (4 yr & older) REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 FLUARIX 20132014 influenza virus vaccine tvs 2013-2014 (36 mos and older)/pf REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 FLUARIX 20142015 influenza virus vaccine trival 2014-15 (36 mos and older)/pf REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 FLUARIX QUAD influenza virus vaccine quad 2013-2014 vs 2013-2014(36 mos & older)/pf REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 FLUARIX QUAD influenza virus vaccine 2014-2015 quadrival 2014-15(36 mos & older)/pf REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 flura-drops REMOVE FROM FORMULARY Covered Non-Formulary sodium fluoride BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 454 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/28/2016 prenatal one daily prenatal vitamin with ca no.129/ferrous fumarate/folic acid REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 multivitamin with fluoride,multivitamin with fluoride,multivita mins with fluoride pediatric multivitamins no.17 with sodium fluoride,pediatric multivitamins combination no.12/sodium fluoride REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 multivitamin with pediatric multivitamins no.17 fluoride,multiwith sodium fluoride vitamin with fluoride,multivita mins with fluoride REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 FLUCELVAX 2014-2015 influenza vaccine trival.split 2014-15 (18 yr+) cell der/pf REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 FLUCELVAX influenza vaccine tv split 2013-14 (18 yr+) cell derived/pf REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 FLUMIST influenza virus vaccine qval live 2013-2014 (2 yrs-49 yrs) REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 FLUMIST QUAD influenza vaccine 2014-2015 quadrivalent live 2014-2015 (2 yrs-49 yrs) REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 ribasphere ribavirin REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 ribasphere ribavirin REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 FLUVIRIN 2013- influenza virus vaccine tv 2014 split 2013-2014 (4 yr & older)/pf REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 FLUVIRIN 2014- influenza virus vaccine 2015 trivalnt 2014-2015 (4 yr & older)/pf REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 455 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/28/2016 FLUVIRIN 2014- influenza virus vaccine 2015 trivalent 2014-2015 (4 yr & older) REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 children's acetaminophen acetaminophen REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 potassium chloride potassium chloride REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 SINGLE USE EZ influenza virus vaccine tv FLU 2013-2014 split 2013-2014 (4 yr & older)/pf REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 SINGLE USE EZ influenza virus vaccine quad FLU 2013-2014 vs 2013-2014(36 mos & older)/pf REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 SINGLE USE EZ influenza virus vaccine quad FLU 2013-2014 vs 2013-2014(36 mos & older)/pf REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 SINGLE USE EZ influenza vaccine trival.split FLU 2014-2015 2014-15 (18 yr+) cell der/pf REMOVE FROM FORMULARY Covered Non-Formulary 03/28/2016 geri-hydrolac ammonium lactate REMOVE FROM FORMULARY Covered Non-Formulary 03/29/2016 disopyramide phosphate disopyramide phosphate ADD UM: AGE 0 to 64 yrs old 03/29/2016 memantine hcl memantine hcl CHANGE TIER Covered 03/29/2016 memantine hcl memantine hcl ADD UM: AGE At least 40 yrs old 03/29/2016 memantine hcl memantine hcl CHANGE UM: AUTHORIZATION PA applies 03/29/2016 ferrous sulfate ferrous sulfate ADD UM: AGE Up to 12 yrs old BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 456 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name 03/29/2016 lactocal-f,vynatalfa,mynatalz,mynatal plus,prenatal 11,prenatal plus,prenatal z prenatal vitamins with calcium/ferrous fumarate/folic acid,prenatal vitamins/ferrous fumarate/folic acid ADD UM: AGE 12 to 55 yrs old 03/29/2016 O-CAL FA prenatal vitamins with calcium/ferrous fumarate/folic acid ADD UM: AGE 12 to 55 yrs old 03/29/2016 prenatal vitamins prenatal vitamins with calcium/ferrous fumarate/folic acid,prenatal vitamin with ca no.130/ferrous fumarate/folic acid,prenatal vitamins/ferrous fumarate/folic acid ADD UM: AGE 12 to 55 yrs old 03/29/2016 right step prenatal vitamins with prenatal vitamins calcium/ferrous fumarate/folic acid ADD UM: AGE 12 to 55 yrs old 03/29/2016 mynate 90 plus ADD UM: AGE 12 to 55 yrs old 03/29/2016 methylergonovine methylergonovine maleate maleate ADD UM: AGE 0 to 12 yrs old 03/29/2016 clarithromycin clarithromycin ADD UM: AGE 0 to 12 yrs old 03/29/2016 clarithromycin clarithromycin ADD UM: AGE 0 to 12 yrs old 03/29/2016 cyclobenzaprine hcl cyclobenzaprine hcl ADD UM: AGE 0 to 64 yrs old prenatal vitamins with calcium/ferrous fumarate/docusate/fa Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 457 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name 03/29/2016 prenatal vitamins,prenatal, stuart prenatal,prenatal formula prenatal vitamins with calcium/ferrous fumarate/folic acid,prenatal vitamins/ferrous fumarate/folic acid,prenatal vits w-ca,fe,fa(<1mg) 03/29/2016 gengraf 03/29/2016 Type of Change Previous Value New Value ADD UM: AGE 12 to 55 yrs old cyclosporine, modified ADD UM: QUANTITY 0 / 12 days cyclosporine cyclosporine, modified ADD UM: AGE 0 to 12 yrs old 03/29/2016 obstetrix dha prenatal vitamins no.12/iron,carbonyl/fa/docus ate/omega-3 ADD UM: AGE 12 to 55 yrs old 03/29/2016 meperidine hcl meperidine hcl ADD UM: AGE 0 to 64 yrs old 03/29/2016 meperidine hcl meperidine hcl ADD UM: AGE 0 to 64 yrs old 03/29/2016 NOVOLOG MIX insulin aspart protamine 70-30 human/insulin aspart FLEXPEN,NOVO LOG MIX 70-30 ADD UM: AGE 0 to 21 yrs old 03/29/2016 orphenadrine citrate orphenadrine citrate ADD UM: AGE 0 to 64 yrs old 03/29/2016 chlorzoxazone chlorzoxazone ADD UM: AGE 0 to 64 yrs old 03/29/2016 baclofen baclofen ADD UM: AGE 0 to 64 yrs old 03/29/2016 baclofen baclofen ADD UM: AGE 0 to 64 yrs old 03/29/2016 cyclobenzaprine hcl cyclobenzaprine hcl ADD UM: AGE 0 to 64 yrs old 03/29/2016 HUMULIN insulin nph human N,NOVOLIN N isophane,nph, human insulin INNOLET,HUMU isophane LIN N KWIKPEN ADD UM: AGE 0 to 21 yrs old 03/29/2016 ondansetron hcl ondansetron hcl ADD UM: AGE 0 to 12 yrs old 03/29/2016 CIPRODEX ciprofloxacin hcl/dexamethasone ADD UM: AGE Up to 12 yrs old BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 458 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/29/2016 memantine hcl memantine hcl ADD UM: AGE At least 40 yrs old 03/29/2016 memantine hcl memantine hcl ADD UM: AGE At least 40 yrs old 03/29/2016 vinate ii prenatal vitamins with calcium/fe bisgly/folic acid ADD UM: AGE 12 to 55 yrs old 03/29/2016 cetirizine hcl cetirizine hcl ADD UM: AGE 0 to 12 yrs old 03/29/2016 children's cetirizine hcl cetirizine hcl ADD UM: AGE 0 to 12 yrs old 03/29/2016 children's walcetirizine hcl zyr,cetirizine hcl,all day allergy,children's cetirizine hcl,children's zyrtec,zyrtec,chil dren's allergy relief,allergy relief ADD UM: AGE 0 to 12 yrs old 03/29/2016 tretinoin tretinoin ADD UM: AGE 10 to 29 yrs old 03/29/2016 tretinoin tretinoin ADD UM: AGE 10 to 29 yrs old 03/29/2016 tretinoin tretinoin ADD UM: AGE 10 to 29 yrs old 03/29/2016 tretinoin tretinoin ADD UM: AGE 10 to 29 yrs old 03/29/2016 tretinoin tretinoin ADD UM: AGE 10 to 29 yrs old 03/29/2016 OBSTETRIX EC prenatal vitamin w-o calcium/iron,carbonyl/docus ate/fa ADD UM: AGE 12 to 55 yrs old 03/29/2016 HUMULIN 70/30 insulin nph human KWIKPEN isophane/insulin regular, human ADD UM: AGE 0 to 21 yrs old BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 459 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/29/2016 completenate prenatal vitamins combo no.14/ferrous fumarate/folic acid ADD UM: AGE 12 to 55 yrs old 03/29/2016 M-VIT prenatal vitamin w-o calcium/ferrous fumarate/folic acid ADD UM: AGE 12 to 55 yrs old 03/29/2016 APIDRA SOLOSTAR insulin glulisine ADD UM: AGE 0 to 21 yrs old 03/29/2016 triveenprenatal vits without calc u,prenatal-u,pnv- no5/ferrous fumarate/folic vp-u acid ADD UM: AGE 12 to 55 yrs old 03/29/2016 ARMOUR THYROID thyroid,pork ADD UM: AGE 0 to 64 yrs old 03/29/2016 ARMOUR THYROID thyroid,pork ADD UM: AGE 0 to 64 yrs old 03/29/2016 armour thyroid,np thyroid,pork,thyroid thyroid,thyroid ADD UM: AGE 0 to 64 yrs old 03/29/2016 armour thyroid,np thyroid,pork thyroid ADD UM: AGE 0 to 64 yrs old 03/30/2016 ARMOUR THYROID thyroid,pork ADD UM: AGE 0 to 64 yrs old 03/30/2016 ARMOUR THYROID thyroid,pork ADD UM: AGE 0 to 64 yrs old 03/30/2016 ARMOUR THYROID thyroid,pork ADD UM: AGE 0 to 64 yrs old 03/30/2016 ARMOUR THYROID thyroid,pork ADD UM: AGE 0 to 64 yrs old 03/30/2016 cetirizine hcl cetirizine hcl ADD UM: AGE 0 to 12 yrs old 03/30/2016 taron-bc prenatal vit with calcium comb no.63/iron,carbonyl/fa/b6 ADD UM: AGE 12 to 55 yrs old BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 460 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/30/2016 prenatal plus,prenatal vitamin plus low iron,preplus prenatal vits with calcium #72/ferrous fumarate/folic acid ADD UM: AGE 12 to 55 yrs old 03/30/2016 prenatal low prenatal vits with calcium iron,vol#74/ferrous fumarate/folic plus,prenaplus,ni acid va-plus ADD UM: AGE 12 to 55 yrs old 03/30/2016 PRENATABS RX prenatal vits with calcium #76/iron,carbonyl/folic acid ADD UM: AGE 12 to 55 yrs old 03/30/2016 vol-tab rx prenatal vits with calcium #76/iron,carbonyl/folic acid ADD UM: AGE 12 to 55 yrs old 03/30/2016 pnv 29-1 prenatal vits with calcium #76/iron,carbonyl/folic acid ADD UM: AGE 12 to 55 yrs old 03/30/2016 volnate,trinate,virt nate,virt-nate prenatal vits with calcium #73/ferrous fumarate/folic acid ADD UM: AGE 12 to 55 yrs old 03/30/2016 co-natal fa,venatalfa,prenatabs fa,pretab prenatal vitamins comb no.78/ferrous fumarate/folic acid,prenatal vits with calcium #78/ferrous fumarate/folic acid ADD UM: AGE 12 to 55 yrs old 03/30/2016 prefera ob,hemenatal ob,vp-heme ob prenatal vit no.21/iron polysacch,heme polypep/folic acid ADD UM: AGE 12 to 55 yrs old 03/30/2016 NATURETHROID thyroid,pork ADD UM: AGE 0 to 64 yrs old 03/30/2016 WESTHROID thyroid,pork ADD UM: AGE 0 to 64 yrs old 03/30/2016 NATURETHROID thyroid,pork ADD UM: AGE 0 to 64 yrs old 03/30/2016 NATURETHROID thyroid,pork ADD UM: AGE 0 to 64 yrs old BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 461 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/30/2016 nestabs,nutri-tab prenatal vitamin no.86/iron ob,vbis-glycinate/folic acid natal,newgen ADD UM: AGE 12 to 55 yrs old 03/30/2016 tri-tabs dha prenatal vitamins comb no.87/iron bisgly/folic acid/dha ADD UM: AGE 12 to 55 yrs old 03/30/2016 NESTABS DHA prenatal vitamins comb no.87/iron bisgly/folic acid/dha ADD UM: AGE 12 to 55 yrs old 03/30/2016 TAMIFLU oseltamivir phosphate ADD UM: AGE 0 to 12 yrs old 03/30/2016 NATUREthyroid,pork THROID,WESTH ROID,WESTHRO ID-P,WP THYROID ADD UM: AGE 0 to 64 yrs old 03/30/2016 THERANATAL prenatal vitamins combo no.28/ferrous fumarate/folic acid ADD UM: AGE 12 to 55 yrs old 03/30/2016 NATURETHROID thyroid,pork ADD UM: AGE 0 to 64 yrs old 03/30/2016 prenatal prenatal vits with calcium multivitamins,pre #95/ferrous fumarate/folic natal acid vitamins,prenatal, prenatal formula ADD UM: AGE 12 to 55 yrs old 03/30/2016 NATURETHROID thyroid,pork ADD UM: AGE 0 to 64 yrs old 03/30/2016 NATURETHROID thyroid,pork ADD UM: AGE 0 to 64 yrs old 03/30/2016 NATURETHROID thyroid,pork ADD UM: AGE 0 to 64 yrs old BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 462 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/30/2016 TRICARE prenatal vits with calcium#103/ferrous fumarate/folic acid ADD UM: AGE 12 to 55 yrs old 03/30/2016 prenatal multi + dha prenatal vitamin no.51/iron fumarate/fa/omega3/dha/epa ADD UM: AGE 12 to 55 yrs old 03/30/2016 prenatal plus prenatal vits with calcium #72/iron,carbonyl/folic acid ADD UM: AGE 12 to 55 yrs old 03/30/2016 PRENATE AM prenatal vitamins no.114/methyltetrahydfolate gluc,fa/ginger ADD UM: AGE 12 to 55 yrs old 03/30/2016 prenatal 19 prenatal vits with calcium#118/ferrous fumarate/folic acid,prenatal vitamins comb no.115/iron fumarate/folic acid ADD UM: AGE 12 to 55 yrs old 03/30/2016 EPANED enalapril maleate ADD UM: AGE 0 to 12 yrs old 03/30/2016 indomethacin indomethacin ADD UM: AGE 0 to 64 yrs old 03/30/2016 HEMANGEOL propranolol hcl ADD UM: AGE 0 to 4 yrs old 03/30/2016 penicillin v potassium penicillin v potassium ADD UM: AGE 0 to 12 yrs old 03/30/2016 penicillin v potassium penicillin v potassium ADD UM: AGE 0 to 12 yrs old 03/30/2016 amoxicillin amoxicillin ADD UM: AGE 0 to 12 yrs old 03/30/2016 amoxicillin amoxicillin CHANGE TIER Covered 03/30/2016 amoxicillin amoxicillin ADD UM: AGE 0 to 12 yrs old 03/30/2016 cefaclor cefaclor CHANGE TIER Covered 03/30/2016 cefaclor cefaclor ADD UM: AGE 0 to 12 yrs old 03/30/2016 cefaclor cefaclor CHANGE TIER Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 463 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/30/2016 cefaclor cefaclor ADD UM: AGE 0 to 12 yrs old 03/30/2016 cefaclor cefaclor ADD UM: AGE 0 to 12 yrs old 03/30/2016 doxycycline doxycycline monohydrate monohydrate,dox ycycline CHANGE TIER Covered 03/30/2016 doxycycline doxycycline monohydrate monohydrate,dox ycycline ADD UM: AGE 0 to 12 yrs old 03/30/2016 nitrofurantoin nitrofurantoin ADD UM: AGE 0 to 12 yrs old 03/30/2016 caffeine citrate caffeine citrated ADD UM: AGE 0 to 1 yrs old 03/30/2016 ciprofloxacin ciprofloxacin ADD UM: AGE 0 to 12 yrs old 03/30/2016 ciprofloxacin ciprofloxacin ADD UM: AGE 0 to 12 yrs old 03/30/2016 mycophenolate mofetil mycophenolate mofetil ADD UM: AGE 0 to 12 yrs old 03/30/2016 synthroid,levothyr levothyroxine sodium oxine sodium,levothroid ,unithroid,levoxyl ADD UM: AGE 0 to 64 yrs old 03/30/2016 synthroid,levothyr levothyroxine sodium oxine sodium,levothroid ,unithroid,levoxyl ADD UM: AGE 0 to 64 yrs old BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 464 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/30/2016 cetirizine cetirizine hcl hcl,children's all day allergy,children's wal-zyr,walzyr,children's zyrtec,all day allergy,children's allergy relief,children's cetirizine hcl,children's allergy,children's allergy complete,children 's allertec,children's zyrtec hives relief,zyrtec,allerg y relief REMOVE UM: QUANTITY 03/30/2016 cefpodoxime proxetil cefpodoxime proxetil ADD UM: AGE 0 to 12 yrs old 03/30/2016 cefpodoxime proxetil cefpodoxime proxetil ADD UM: AGE 0 to 12 yrs old 03/30/2016 letrozole,femara letrozole REMOVE UM: AUTHORIZATION 03/30/2016 letrozole letrozole ADD UM: AGE At least 18 yrs old 03/30/2016 trimesis prenatal without iron/folic rx,folinatal plus acid/calcium b,folbecal,premes carb/pyridoxine/b12 is rx,previte rx,combi rx ADD UM: AGE 12 to 55 yrs old 03/30/2016 HUMALOG MIX insulin lispro protamine and 50-50 KWIKPEN insulin lispro ADD UM: AGE 0 to 21 yrs old PA applies BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 465 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/30/2016 diflucan,fluconaz fluconazole ole REMOVE UM: AGEQUANTITY 03/30/2016 fluconazole fluconazole ADD UM: AGE 03/30/2016 diflucan,fluconaz fluconazole ole REMOVE UM: AGEQUANTITY 03/30/2016 fluconazole fluconazole ADD UM: AGE 03/30/2016 fluconazole fluconazole REMOVE UM: AGEQUANTITY 03/30/2016 pulmicort,budeso budesonide nide REMOVE UM: AGEQUANTITY 03/30/2016 budesonide ADD UM: AGE 0 to 6 yrs old 03/30/2016 butalbital-aspirin- butalbital/aspirin/caffeine caffeine ADD UM: AGE 0 to 64 yrs old 03/30/2016 esgic,butalbital- butalbital/acetaminophen/caf acetaminophen- feine caffe,margesic,al agesic,anolor300,capacet,triad ,medigesic,zebut al ADD UM: AGE 10 to 64 yrs old 03/30/2016 butalbitalacetaminophencaffe ADD UM: AGE 10 to 64 yrs old 03/30/2016 phrenilin,butalbita butalbital/acetaminophen lacetaminophen, martentab,acetaminoph enbutalbital,tencon ADD UM: AGE 10 to 64 yrs old budesonide butalbital/acetaminophen/caf feine 0 to 12 yrs old 0 to 12 yrs old BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 466 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/30/2016 phrenilin,butalbita butalbital/acetaminophen lacetaminophen, martentab,acetaminoph enbutalbital,tencon REMOVE UM: AGEQUANTITY 03/30/2016 butalbitalbutalbital/acetaminophen acetaminophen,a cetaminophenbutalbital ADD UM: AGE 03/30/2016 butalbitalbutalbital/acetaminophen acetaminophen,a cetaminophenbutalbital CHANGE UM: CUSTOM 03/30/2016 rivastigmine rivastigmine tartrate ADD UM: AGE At least 40 yrs old 03/30/2016 rivastigmine rivastigmine tartrate ADD UM: AGE At least 40 yrs old 03/30/2016 rivastigmine rivastigmine tartrate ADD UM: AGE At least 40 yrs old 03/30/2016 rivastigmine rivastigmine tartrate ADD UM: AGE At least 40 yrs old 03/30/2016 RELENZA zanamivir ADD UM: CUSTOM Max 10 per 180 days 03/30/2016 NOVOLOG FLEXPEN insulin aspart ADD UM: AGE 0 to 21 yrs old 03/30/2016 NOVOLOG FLEXPEN insulin aspart REMOVE UM: AUTHORIZATION 03/30/2016 calcitriol calcitriol 10 to 64 yrs old Cumulative: 4gm/day acetaminophen Cumulative: 4Mg/Day Acetaminophen. PA applies ADD UM: AGE 0 to 12 yrs old BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 467 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/30/2016 HUMALOG MIX insulin lispro protamine & 75-25,HUMALOG insulin lispro,insulin lispro MIX 75-25 protamine and insulin lispro KWIKPEN ADD UM: AGE 0 to 21 yrs old 03/30/2016 HUMALOG MIX insulin lispro protamine & 75-25,HUMALOG insulin lispro,insulin lispro MIX 75-25 protamine and insulin lispro KWIKPEN REMOVE UM: AUTHORIZATION 03/30/2016 montelukast sodium montelukast sodium ADD UM: AGE At least 15 yrs old 03/30/2016 vinate-m prenatal vitamins with calcium/ferrous fumarate/fa/selenium ADD UM: AGE 12 to 55 yrs old 03/30/2016 p-d natal plus,kpn,prenatal vitamins,p-d natal plus with folic acid,prenatal prenatal vits wca,fe,fa(<1mg),prenatal vit calc,iron,folic acid (less than 1 mg) ADD UM: AGE 12 to 55 yrs old 03/30/2016 mynatal prenatal vitamins with calcium/iron,carbonyl/docus ate/fa ADD UM: AGE 12 to 55 yrs old 03/30/2016 HUMALOG insulin lispro KWIKPEN U-100 ADD UM: AGE 0 to 21 yrs old 03/30/2016 LANTUS SOLOSTAR insulin glargine,human recombinant analog,insulin glargine, human recombinant analog REMOVE UM: STEP ST applies 03/30/2016 LANTUS SOLOSTAR insulin glargine,human recombinant analog,insulin glargine, human recombinant analog REMOVE UM: AUTHORIZATION PA applies PA applies BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 468 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name 03/30/2016 LANTUS SOLOSTAR 03/30/2016 Generic Name insulin glargine,human recombinant analog,insulin glargine, human recombinant analog Type of Change Previous Value New Value ADD UM: AGE 0 to 21 yrs old triadvance,mynat prenatal vitamin al no.15/iron,carbonyl/folic advance,prenatal acid/docusate sod ad,inatal advance,advance d natalcare,virtadvance ADD UM: AGE 12 to 55 yrs old 03/30/2016 trinatal gt,vinate gt,natalcare,virtvite gt prenatal vitamin no.16/iron,carbonyl/folic acid/docusate sod ADD UM: AGE 12 to 55 yrs old 03/30/2016 trinatal prenatal vitamin ultra,vinate no.18/iron,carbonyl/folic ultra,prenacare,in acid/docusate sod atal ultra,ultra natalcare ADD UM: AGE 12 to 55 yrs old 03/30/2016 NATUREthyroid,pork THROID,WESTH ROID,WESTHRO ID-P,WP THYROID ADD UM: AGE 0 to 64 yrs old 03/31/2016 NATUREthyroid,pork THROID,WESTH ROID,WESTHRO ID-P,WP THYROID ADD UM: AGE 0 to 64 yrs old 03/31/2016 naturethyroid,pork,thyroid throid,westhroid, westhroid-p,wp thyroid,thyroid ADD UM: AGE 0 to 64 yrs old BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 469 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 naturethyroid,pork,thyroid throid,westhroid, westhroid-p,wp thyroid,thyroid ADD UM: AGE 0 to 64 yrs old 03/31/2016 ferrous sulfate,ferosul ADD UM: AGE 0 to 12 yrs old 03/31/2016 trinatal rx 1,seprenatal vitamin 27 with natal one,vinate calcium/ferrous one,prenatal rx 1 fumarate/folic acid ADD UM: AGE 12 to 55 yrs old 03/31/2016 minocycline hcl,minocin minocycline hcl REMOVE UM: AGE 03/31/2016 minocycline hcl minocycline hcl REMOVE UM: AGE 03/31/2016 minocycline hcl,minocin minocycline hcl REMOVE UM: AGE 03/31/2016 minocycline hcl minocycline hcl REMOVE UM: AGE 03/31/2016 doxycycline doxycycline monohydrate monohydrate,mo nodox,mondoxyn e nl REMOVE UM: AGE 03/31/2016 doxycycline monohydrate doxycycline monohydrate REMOVE UM: AGE 03/31/2016 doxycycline doxycycline monohydrate monohydrate,mo nodox,mondoxyn e nl REMOVE UM: AGE 03/31/2016 cipro,ciprofloxaci ciprofloxacin hcl n hcl REMOVE UM: AGE 03/31/2016 CIPRO ciprofloxacin hcl REMOVE FROM FORMULARY 03/31/2016 ciprofloxacin hcl ciprofloxacin hcl CHANGE TIER 03/31/2016 CIPRO ciprofloxacin hcl REMOVE UM: AGE ferrous sulfate At least 8 yrs old Covered Non-Formulary Covered At least 8 yrs old BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 470 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value Non-Formulary 03/31/2016 ciprofloxacin hcl,cipro ciprofloxacin hcl REMOVE UM: AGE 03/31/2016 CIPRO ciprofloxacin hcl REMOVE FROM FORMULARY Covered 03/31/2016 ciprofloxacin hcl,cipro ciprofloxacin hcl REMOVE UM: AGE At least 18 yrs old 03/31/2016 ciprofloxacin hcl ciprofloxacin hcl REMOVE UM: AGE At least 8 yrs old 03/31/2016 ramipril,altace ramipril REMOVE UM: AGE At least 55 yrs old 03/31/2016 ramipril,altace ramipril REMOVE UM: AGE At least 55 yrs old 03/31/2016 ramipril,altace ramipril REMOVE UM: AGE 03/31/2016 ramipril ramipril CHANGE TIER 03/31/2016 ramipril,altace ramipril REMOVE UM: AGE 03/31/2016 ramipril ramipril CHANGE TIER 03/31/2016 EMCYT estramustine phosphate sodium 03/31/2016 evista,raloxifene hcl raloxifene hcl ADD UM: AGE At least 40 yrs old 03/31/2016 raloxifene hcl raloxifene hcl ADD UM: AGE At least 40 yrs old 03/31/2016 raloxifene hcl raloxifene hcl ADD UM: GENDER Female 03/31/2016 enoxaparin sodium enoxaparin sodium ADD UM: AUTHORIZATION PA applies 03/31/2016 enoxaparin sodium enoxaparin sodium ADD UM: AUTHORIZATION PA applies 03/31/2016 enoxaparin sodium enoxaparin sodium ADD UM: AUTHORIZATION PA applies CHANGE UM: GENDER Covered Covered Female Male BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 471 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 enoxaparin sodium enoxaparin sodium ADD UM: AUTHORIZATION PA applies 03/31/2016 enoxaparin sodium enoxaparin sodium ADD UM: AUTHORIZATION PA applies 03/31/2016 enoxaparin sodium enoxaparin sodium ADD UM: AUTHORIZATION PA applies 03/31/2016 enoxaparin sodium enoxaparin sodium ADD UM: AUTHORIZATION PA applies 03/31/2016 HUMIRA adalimumab PEN,HUMIRA PEN CROHNUC-HS STARTER,HUMI RA PEN PSORIASISUVEITIS ADD UM: AUTHORIZATION PA applies 03/31/2016 HUMIRA PEN CROHN-UC-HS STARTER adalimumab ADD UM: AUTHORIZATION PA applies 03/31/2016 heartburn relief 24 hour lansoprazole REMOVE UM: AUTHORIZATION PA applies 03/31/2016 heartburn lansoprazole treatment 24 hour REMOVE UM: AUTHORIZATION PA applies 03/31/2016 PREVACID lansoprazole REMOVE UM: AUTHORIZATION PA applies 03/31/2016 PREVACID 24HR lansoprazole REMOVE UM: AUTHORIZATION PA applies 03/31/2016 oxycodone hcl oxycodone hcl REMOVE UM: AUTHORIZATION PA applies 03/31/2016 ZETIA ezetimibe REMOVE UM: AUTHORIZATION PA applies BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 472 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 hydrea,hydroxyur hydroxyurea ea REMOVE UM: AUTHORIZATION PA applies 03/31/2016 fluocinonidee,fluocinonide emollient fluocinonide/emollient base REMOVE UM: AUTHORIZATION PA applies 03/31/2016 leucovorin calcium leucovorin calcium REMOVE UM: AUTHORIZATION PA applies 03/31/2016 leucovorin calcium leucovorin calcium REMOVE UM: AUTHORIZATION PA applies 03/31/2016 leucovorin calcium leucovorin calcium REMOVE UM: AUTHORIZATION PA applies 03/31/2016 leucovorin calcium leucovorin calcium REMOVE UM: AUTHORIZATION PA applies 03/31/2016 aromasin,exemes exemestane tane REMOVE UM: AUTHORIZATION PA applies 03/31/2016 AROMASIN exemestane REMOVE FROM FORMULARY Covered 03/31/2016 HUMULIN 7030,NOVOLIN 7030 INNOLET,HUMU LIN 70/30 KWIKPEN insulin nph human isophane/insulin regular, human,nph, human insulin isophane/insulin regular, human REMOVE UM: STEP ST applies 03/31/2016 VICTOZA 2liraglutide PAK,VICTOZA 3PAK REMOVE UM: STEP ST applies 03/31/2016 omeprazole omeprazole CHANGE TIER Covered 03/31/2016 oxybutynin chloride er oxybutynin chloride CHANGE TIER Covered 03/31/2016 oxybutynin chloride er oxybutynin chloride CHANGE TIER Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 473 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value 03/31/2016 ondansetron odt ondansetron CHANGE TIER 03/31/2016 JANUMET XR sitagliptin phosphate/metformin hcl REMOVE UM: STEP ST applies 03/31/2016 JANUMET XR sitagliptin phosphate/metformin hcl REMOVE UM: STEP ST applies 03/31/2016 JANUMET XR sitagliptin phosphate/metformin hcl REMOVE UM: STEP ST applies 03/31/2016 pantoprazole sodium pantoprazole sodium 03/31/2016 elimite 03/31/2016 New Value Covered CHANGE TIER Covered permethrin REMOVE FROM FORMULARY Non-Formulary omeprazole omeprazole CHANGE TIER Covered 03/31/2016 oxybutynin chloride er oxybutynin chloride CHANGE TIER Covered 03/31/2016 balsalazide disodium balsalazide disodium CHANGE TIER Covered 03/31/2016 pantoprazole sodium pantoprazole sodium CHANGE TIER Covered 03/31/2016 JANUMET sitagliptin phosphate/metformin hcl REMOVE UM: STEP ST applies 03/31/2016 JANUMET sitagliptin phosphate/metformin hcl REMOVE UM: STEP ST applies 03/31/2016 ASACOL HD mesalamine ADD UM: STEP 03/31/2016 vitamin d3,vitamin d cholecalciferol (vitamin d3) REMOVE FROM FORMULARY ST applies Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 474 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 women's bisacodyl laxative,laxative,l axative feminine,correctol ,feen-amint,gentle laxative,woman's laxative,sb gentle laxwomen,fematrol laxative,exlax,corrective laxative REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 senna,senna sennosides laxative,medinatural,vegetable laxative,natural senna laxative,senno,se nokot,senna lax,sennagen,sen okot to go,sennagen,sen-otab,natural vegetable laxative,sennac,sennosides,sen na concentrate,evac -ugen,senexon,sen nacon,gerikot,laxative REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 laxative sennosides pills,medi-lax,exlax,perdiem,senn a soft,laxative REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 475 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 sodium polystyrene sulfonate,sps sodium polystyrene sulfonate,sodium polystyrene sulfonate/sorbitol solution REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 sodium polystyrene sulfonate sodium polystyrene sulfonate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 hydralazine hcl hydralazine hcl REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 hydralazine hcl hydralazine hcl REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 hydralazine hcl hydralazine hcl REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 hydralazine hcl hydralazine hcl REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 hydralazine hcl hydralazine hcl REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 minoxidil minoxidil REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 minoxidil minoxidil REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 sodium polystyrene sulfonate,sps,kio nex sodium polystyrene sulfonate,sodium polystyrene sulfonate/sorbitol solution REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 kionex,sodium sodium polystyrene polystyrene sulfonate sulfonate,kayexal ate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 sodium phosphate REMOVE FROM FORMULARY Covered Non-Formulary sodium phos,m-basic-dbasic BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 476 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 potassium phosphate potassium phos,m-basic-dbasic REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 CALCI-MIX calcium carbonate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 oyster shell calcium carbonate,calcium calcium,calcium,c alcium carbonate,natural calcium,oysco500,oyst-cal500,hi-cal,natural o-s cal REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium,calcium calcium carbonate carbonate,caltrat e 600,calcarb 600,high potency calcium,super calcium REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcicalcium carbonate chew,calcium,cal cium carbonate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium chloride calcium chloride REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium chloride calcium chloride REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium gluconate calcium gluconate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium gluconate calcium gluconate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium lactate calcium lactate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 magnesium chloride magnesium chloride REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 477 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 magnesium gluconate magnesium gluconate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 magnesium magnesium oxide REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 mgo,magnesium magnesium oxide oxide,magnesium ,magox 400,magox,diase nse magnesium REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 magnesium magnesium oxide oxide,magnesium REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 magnesium oxide,maox magnesium oxide REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 laxative dietary magnesium oxide supplement,mag nesium oxide,phillips REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 magnesium sulfate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 magnesium,mag magnesium,magnesium nesium oxide oxide REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 magnesium,mag magnesium,magnesium nesium gluconate gluconate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 magnesium,mag magnesium nesium gluconate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 mag-tab sr,magbid er REMOVE FROM FORMULARY Covered Non-Formulary magnesium sulfate magnesium l-lactate BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 478 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 renal caps,nephrocaps, renalpren,renal softgel,reno caps,virtcaps,triphrocaps, mynephrocaps vitamin b complex and vitamin c no.20/folic acid,folic acid/vitamin b comp w-c,vitamin b complex & vitamin c no.20/folic acid REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 iron dextran complex,infed iron dextran complex REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ferrocite,ferrous ferrous fumarate fumarate,hemocy te REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 polysaccharide iron polysaccharides iron complex,iron polysaccharide 150,polysacchari complex de iron,ferrex 150,ferus,altorex, ferric x-150,iferex 150,myferon 150,nu-iron 150,poly-iron REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 iron ferrous sulfate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ferrous sulfate ferrous sulfate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 iron,ferrous ferrous sulfate sulfate,iron supplement,ferro usul,albafort,feos ol,ferosul,ferrotime REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ferrous sulfate REMOVE FROM FORMULARY Covered Non-Formulary ferrous sulfate BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 479 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 iron iron REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 sodium bicarbonate sodium bicarbonate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 sodium bicarbonate sodium bicarbonate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium carbonate calcium carbonate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 alcalak,antacid,tit calcium carbonate ralac REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 antacid,calcalcium carbonate gest,calcium antacid,gaviscon, tums freshers,calcium carbonate,tums REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 antacid extra calcium carbonate strength,calcium antacid,smooth antacid,banacid,antacid,tums x-str,titralac extra strength,tums,cal cium carbonate,tums smoothies,flavor chews antacid,xstrength antacid,tums calcium for life REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 480 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 tums ultra,antacid calcium carbonate ultra strength,calcium carbonate,ultra strength antacid,calcium antacid,maalox quick dissolve REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 children's calcium carbonate soothe,childrens calcium antacid,children's mylanta,children' s pepto,childrens maalox REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 milk of magnesium hydroxide magnesia,phillips' milk of magnesia,ex-lax milk of magnesia REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 phillips',magnesia magnesium hydroxide ,phillips' milk of magnesia REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 aluminum hydroxide aluminum hydroxide REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 alternagel,alumin aluminum hydroxide um hydroxide REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ri-mag,ron-acid REMOVE FROM FORMULARY Covered Non-Formulary magaldrate BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 481 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 fiber calcium polycarbophil laxative,fibertabs,fibercon,fibe r tabs,fiber lax,konsyl fiber,fiber,calcium polycarbophil,fibe r-lax,fiber therapy,fibertab,p erdiem,fibergen REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 equalactin calcium polycarbophil REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 senexon,senna sennosides REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 bisacodyl,laxative bisacodyl suppository,gentl e laxative,bisacevac,dulcolax,ma gic bullet,biscolax,fas t relief laxative REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 bisacodyl REMOVE FROM FORMULARY Covered Non-Formulary bisacodyl BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 482 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 laxative,bisacodyl bisacodyl ,dulcolax,gentle laxative,ducodyl, woman's laxative,women's laxative,bisalax,doxidan,reliab le gentle laxative,women's gentle laxative,alophen pills,bisacevac,stimulant laxative REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 adult glycerin glycerin,colace,gl ycerin,suppositor y,sani-supp REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 glycerin,infant glycerin glycerin,colace,s ani-supp,child suppository,pedia -lax,laxative suppository REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 castor oil castor oil REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 castor oil castor oil REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 mineral oil,mineral oil extra heavy mineral oil REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 483 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 mineral oil,fleet mineral oil mineral oil enema,ready to use enema,mineral oil enema,enema REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 stool docusate calcium softener,docusat e calcium,kaopecta te,calcium stool softener,surfak,k ao-tin,dc-240 REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 stool docusate sodium softener,docusat e sodium,dss,docu soft s,womens stool softener,colace,u ni-ease,soflax,phillips' laxative,dulcolax stool softener,docusil,d ocu soft,dok,colrite,doc-qlace,genasoft,cor rectol extra gentle,woman's laxative-docusate sod REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 docusate docusate sodium sodium,dss,stool softener,colrite,dok REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 484 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 stool docusate sodium softener,colace,c olace clear,colrite REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 colace,docusate docusate sodium sodium,silace,do cu liquid,diocto,stool softener,doc-qlace REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 docusate docusate sodium sodium,stool softener,dioctyl,si lace,colace,dioct o,doc-q-lace REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 pedia-lax stool softener docusate sodium REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 promolaxin,move docusate sodium it along,docuprene, stool softener,docusat e sodium,dok,regut ol REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 epsom salt magnesium sulfate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 magnesium magnesium citrate citrate,citrate of magnesia,citroma REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 485 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 natural vegetable powder,konsyl,fib er therapy,fiber smooth,hydrocil instant,walmucil,fiber laxative,laxmar,m etafiber,natural fiber,vegetable laxative,psyllium, metamucil,reguloi d psyllium seed,methylcellulose,methyl cellulose (with sugar),psyllium seed (with sugar),psyllium husk (with sugar) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 hydrocil instant,natural fiber psyllium seed REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 fiber methylcellulose therapy,citrucel,s oluble fiber REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 fiber,fiber methylcellulose therapy,citrucel,fi ber laxative,soluble fiber REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 fenoldopam fenoldopam mesylate mesylate,corlopa m REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcitrate,calcium calcium citrate citrate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 KRISTALOSE lactulose REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 lactulose,constul lactulose ose REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 486 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 niferex-150 forte,ferrex 150 forte,myferon-150 forte,poly-iron 150 forte,polysacchari de iron forte,iferex 150 forte iron polysaccharide complex/cyanocobalamin/fol ic acid,iron bisgly & ps cmplx/ascorbate ca/b12/folic acid/ca-threo,iron polysaccharides complex/cyanocobalamin/fol ic acid REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 THEREMS-M multivits,th w-fe,other min,multivit,th iron,other min REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 thera-m,uni-thera m,theradex m,therapeuticm,therapeutic vitamin wminerals,therape utic m multivit,therapeutic with iron/calcium/folic acid/minerals,multivit,therap eutic with iron,calcium,folic acid & minerals REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 one daily multivit with calcium, iron, women's,women' and other minerals s one daily,one daily with calciumiron,women's daily formula REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 centavite a-z with multivitamin with minerals,century, iron,hematinic,multivits wcomplete,central- iron,hematinic vite REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 docusol docusate sodium REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ferrous ferrous gluconate gluconate,fergon, iron,ferate REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 487 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 biotin,hard nails biotin REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 KRISTALOSE lactulose REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ex-lax,chocolated sennosides laxative,laxative REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 vitamin d,vitamin cholecalciferol (vitamin d3) d3,thera-d,d3 dots REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 OSMOPREP REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 folcaps,foleve,co cyanocobalamin/folic mbgen,folplex acid/pyridoxine 2.2,folic acid-vit b6-vit b12 REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 fe c plus,icar-c iron,carbonyl/ascorbic plus,iron 100 plus acid/cyanocobalamin/folic acid REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 PROFERRIN REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 rena-vite,full folic acid/vitamin b comp spectrum and c,folic acid/vitamin b b,dialyvite comp w-c 800,renavit,folic acid xtra,nephrovite REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 MAGINEX magnesium aspartate hcl REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 FERRIMIN 150 ferrous fumarate REMOVE FROM FORMULARY Covered Non-Formulary sodium phosphate,m-basic m-hyd/sodium phosphate,dibasic iron heme polypeptide BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 488 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 VITAFOL ferrous fumarate/calcium/vitamin e/folic acid/multivitamin REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ferrocite plus,centratex,re ocyte plus,hemocyte plus ferrous fumarate/folic acid/multivitamins with min no. 15,ferrous fumarate/folic acid/multivitamin-minerals no.15 REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 benefiber,nutriso guar gum urce fiber,fiber,easy fiber REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 BENEFIBER,NU guar gum TRISOURCE FIBER REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 489 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 stool softenersennosides/docusate laxative,easy-lax sodium,sennosides plus,stool softenerstimulant lax,stool softener,medinatural senna stool soft,senna,senna -s,senna laxative,senna plus,sennosidesdocusate sodium,sennadocusate sodium,senna s,senokot-s,p-col rite,docusate sodiumsenna,sennatime s,lax stool softener with senna,doc-qlax,senexons,senna-c plus,pericolace,medilaxx,laxacin,senn alax-s,dok plus,stimulant laxative plus REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium 600 + vit calcium d,liquid calcium carbonate/cholecalciferol 600-vit d3 (vitamin d3) REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 490 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name 03/31/2016 centrum performance,com plete premium vitamin,century advantage,multivi tal performance,cent ral vite,spectravite performance,cent ral-vite performance 03/31/2016 phoslo,calcium acetate 03/31/2016 Generic Name Type of Change Previous Value New Value multivits w-fe,other min/ginkgo biloba extract/k.ginsg,multivit with fe,other mineral/ginkgo biloba extract/p.ginsg REMOVE FROM FORMULARY Covered Non-Formulary calcium acetate REMOVE FROM FORMULARY Covered Non-Formulary maalox calcium advanced,antacid carbonate/simethicone,calci -antigas,maalox um carbonate quick dissolve,maalox REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 LYDIA PINKHAM ferrous sulfate/licorice root HERBAL extract REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 fiber,easy fiber dextrin,psyllium seed (with dextrose) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 RIGINIC magnesium carbonate/aluminum hydroxide/alginic acid REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 gaviscon,foaming magnesium antacid,acid gone carbonate/aluminum antacid,genaton hydroxide/alginic acid REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 491 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 metamucil,natural psyllium husk (with sugar) fiber laxative,natural vegetable fiber,natural fiber,walmucil,fiber,natural daily fiber,fiber laxative REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 century cardio multivits,ca,minerals/iron/foli health,spectravite c acid/lycopene/lut/phytoster cardio health REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 natural psyllium psyllium husk/aspartame fiber,metamucil,m etamucil sugarfree,walmucil,metamucil multihealth fiber,fiber,natural fiber supplement,gerimucil,natural vegetable fiber,natural fiber laxative,natural daily fiber REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 vitamin d3ca comb no.1/vitamin aloe,heartburn & d3/pyridoxine hcl/fa/vit acid reflux b12/aloe vera REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 fiber,metamucil,n psyllium husk (with sugar) atural fiber laxative,natural vegetable fiber,konsyl REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 492 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name 03/31/2016 fiber,natural vegetable powder,metamuci l,wal-mucil natural fiber lax,konsyl,daily fiber,natural fiber,natural fiber laxative 03/31/2016 Generic Name Type of Change Previous Value New Value REMOVE FROM FORMULARY Covered Non-Formulary multivital,sentry,a multivit,calcium,other thru z,centralmin/ferrous vite,vitatrum,com fumarate/fa/lycopene/lut plete,complete multi REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 vitamin e vitamin e (dl-alpha tocopheryl acetate) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 vitamin e vitamin e (dl-alpha tocopheryl acetate) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 NUTRICAP folic acid/multivit with fe,other mineral REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ZEMPLAR paricalcitol REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 hematron-af,tlhem 150,hemax iron,carbonyl/docusate sodium/b12-if/folic acid/multivit-min REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calciummagnesium calcium/magnesium REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 LIFE-PACK multivitamin with iron and other minerals REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 LIFE-PACK bioflavonoids/multivit with fe,other mineral REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 vitamin e,e-200 vitamin e (dl-alpha tocopheryl acetate) REMOVE FROM FORMULARY Covered Non-Formulary psyllium husk (with sugar),psyllium seed/aspartame,psyllium seed (with sugar) BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 493 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value lysine hcl/vitamin b complex/folic acid/zinc REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 SUPERVITE 03/31/2016 calcium citrate - calcium vitamin d,calcium citrate/cholecalciferol citrate-vit (vitamin d3) d,citracal + d,citrus calcium + d,calcium citratevitamin d3,calcium citrate - vitamin d3,calcium citrate-vitamin d,calcium citrate+d,citracal +d maximum,calcitra te + vit d,calcium citrate- vitamin d REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 viactiv,calcium-vit calcium d3-vit k carbonate/cholecalciferol (vit d3)/phytonadione REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 494 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date 03/31/2016 Brand Name Generic Name multi completemultivitamin/ferrous iron,one daily fumarate/folic acid plus iron,complete multi-vitmineral,centrum complete,sentry perform,century,s pectravite advanced formula,one daily with iron,daily multivitaminiron,a thru z advanced formula,essentia, century ultimate women's,adults' daily formula,sentry,m ulti-vite,complete women,multi-day plus iron,daily vitamin formula + iron,cerovite advanced formula,certaviteantioxidant,centru m ultra women's,yelets,ta b a vite weight slim,daily teen multivitamin,vitatrum complete,one daily multivitaminiron,one-a-day teen advantage,compl Type of Change Previous Value New Value REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 495 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value ete multivitamin,daily multiple,spectravi te ultra women,centralvite,daily multi,daily multiple vitaminsiron 03/31/2016 RENAGEL sevelamer hcl REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 RENAGEL sevelamer hcl REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 hectorol,doxercal doxercalciferol ciferol REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 mega biotin biotin REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 biotin,meribin biotin REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 biotin biotin REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 bifera,feosol,duof iron polysaccharide er complex/iron heme polypeptide REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 PROFERRINFORTE iron heme polypeptide/folic acid REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 NEPHRONEX vitamin b complex with vitamin c no.10/folic acid REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 liquid calcium + calcium vitamin d,calcium carbonate/cholecalciferol carbonate/vitamin (vitamin d3) d3 REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 496 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 iron,feosol iron,carbonyl REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 soy formula calcium carbonate/cholecalciferol (vit d3)/soybean REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 women's complex calcium/magnesium/vit b comp/vitamin d3/herbal complex no.61 REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 FORTAVIT multivit with fe,other mineral/dietary 4/dna/rna REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 fatigue relief complex vitamin b comp and c/st.jhn wrt/siberian ginseng/p.ginsg REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium 500-vit calcium d3,oyster shell carbonate/cholecalciferol calcium-vitamin (vitamin d3) d,oyster shell calcium,oystercal -d,calcium 500 + vit d,oyster shell calcium w-vit d REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 magnesium magnesium oxide/magnesium amino acid chelate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 CORAL CALCIUM calcium/magnesium oxide/cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 497 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 a thru z multivit with fe,other select,essential mineral/lutein,multivits wbalance,theratru fe,other min/lutein m complete,century advanced formula,century complete,essenti al mega,centrum silver ultra women's REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 BEELITH REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 natural fiber,fiber psyllium husk laxative,fiber,dail y fiber,metamucil,k onsyl,fiber therapy,walmucil,psyllium fiber,genfiber,me di-mucil,reguloid REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 laxative sennosides pills,laxative,natu ral laxative,senna laxative,laxative maximum strength,laxativesenna,ex-lax maximum strength REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 natural fiber,fiber psyllium seed,psyllium therapy husk/aspartame REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 vitamin e REMOVE FROM FORMULARY Covered Non-Formulary magnesium oxide/pyridoxine hcl vitamin e acetate/selenium BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 498 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 calcium 600 + vit calcium d carbonate/cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 vitamin d3,vitamin d,children's vitamin d,kids vitamin d3 REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 folgard os,tl g-fol calcium carb/mag os oxide/vitamin d3/vit b12/fa/vit b6/boron REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 THEREMS-H multivit,th iron,other min REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 PRELIEF calcium glycerophosphate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 UNIFIBER cellulose REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 coral calcium calcium carbonate/magnesium/chole calciferol (vit d3) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 coral calcium calcium carbonate/magnesium oxide/cholecalciferol (vit d3) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 cerefolin,l-methyl- cyanocobalamin/levomefolat mc,rovin-cf e of,metafolbic,enfo calcium/pyridoxine/riboflavin last REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 DIALYVITE 800 WITH IRON REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 iron,slow release ferrous sulfate, dried iron REMOVE FROM FORMULARY Covered Non-Formulary cholecalciferol (vitamin d3) ferrous fumarate/folic acid/vitamin b comp and c BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 499 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 HYFIBER,HYFIB fructooligosaccharides/polyd ER WITH FOS extrose REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 one daily,daily multiple REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ferrous gluconate ferrous gluconate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 one daily folic acid/multivitamin wwomens 50 minerals,multivitamin with plus,omnicap,mul minerals/folic acid tivitamins for cholesterol,men's daily formula,one-aday,one daily essential,daily multiple,compani on multi for men,vitalee,one daily carbvantage,quintabs -m iron free,companion,s tress formula advanced,one daily REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 MAG GLYCINATE magnesium glycinate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium gluconate calcium gluconate REMOVE FROM FORMULARY Covered Non-Formulary multivits w-fe,other min/green tea leaf extract,multivitamin with iron,other mineral/green tea leaf extract BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 500 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 calcium citrate calcium +vit d3,citracalcitrate/cholecalciferol vitamin d,citrus (vitamin d3) calcium-vitamin d REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium antacid REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 CITRACAL + calcium carb,citrate/vitamin BONE DENSITY d3/mineral comb no.34/genistein REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 choicemultivit with min#10/folic tabs,strovite one acid//vit d3/a lipoic acid/lutein REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 balanced b100,b-100 complex,b100 balanced vit b complex 100 combo no.2 REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 LIQUAFIBER glycerin/maltodextrin REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 natural balanced vit b complex 100 combo b-100 no.2/herbal drugs REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 senna sennosides REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 slow fe,slow release iron ferrous sulfate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 integra iron fumarate,polysac plus,folivane-plus cplex/folic acid/vit b comp with c #9 REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 INTEGRA REMOVE FROM FORMULARY Covered Non-Formulary calcium carbonate iron fumarate/iron polysac complex/vitamin c/niacinamide BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 501 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 integra f,folivane- iron fumarate,polysac f comp/folic acid/vitamin c/niacinamide REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 therapeuticmultivits, ca, minerals/iron m,one-a-day teen fumarate/folic acid advantage,theram,thera m plus REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 DIALYVITE 3000 folic acid/vitamin b comp and c/selenium/min aa chel/zinc REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 folastin,foltx,folna cyanocobalamin/folic te acid/pyridoxine plus,folamin,allan tex,folic acid,virtvite forte,folbalin plus,folbic,nivafol,cavan-x REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 MAGNEBIND 300 REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 one daily folic acid/multivit with complete,century, fe,other mineral,folic one daily acid/multivits w-fe,other min maximum,one daily for women REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 DIALYVITE ZINC vitamin b complex#11/folic acid/ascorbic acid/biotin/zn oxid REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 doxercalciferol,he doxercalciferol ctorol REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 antacid multisymptom,rolaids multisymptom,rolaids REMOVE FROM FORMULARY Covered Non-Formulary calcium carbonate/magnesium carbonate calcium carbonate/magnesium hydroxide/simethicone BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 502 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 antacid,rolaids extra strength,antacid extra strength calcium carbonate/magnesium hydroxide REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 rolaids extra strength,antacid ultra strength,tums ultra strength calcium carbonate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 GLYCOPHOS sodium glycerophosphate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium 600-vit calcium d3,calcium 600 + carbonate/cholecalciferol vit d,super (vitamin d3) calcium 600-vit d3,super calcium w-vitamin d,calcarb 600 with vitamin d REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 one daily men's multivitamins w50+,one daily for minerals/folic men 50+ acid/lycopene/ginkgo leaf xt advanced,daily multiple REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 HECTOROL REMOVE FROM FORMULARY Covered Non-Formulary doxercalciferol BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 503 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 womens multiple multivit with calcium, iron, vitamins,women's and other minerals daily multivitamin,one daily maximum,essenti al daily,maximum daily multivitamin,tab a vite,therapeutic m REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 bone density calcium + d calcium carbonate/vitamin d3/arginine/inositol/silicon REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 FERRETTS IPS iron succinyl-protein complex REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 DIABETES HEALTH alpha lipoic acid/folic acid/multivitamin with minerals/lut REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 WOMEN'S PACK,MEN'S PACK folic acid/multivitamin wminerals/lutein,folic acid/multivitamin with minerals/lutein REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 MAXIMIN folic acid/multivitamin with minerals/lutein REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 FOSRENOL lanthanum carbonate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 folbee plus cz,diatx zn folic acid/vitamin b comp and c/copper/zinc oxide,folic acid/vitamin b comp wc/copper/zinc oxide REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 one daily multivitamin with iron,other mineral/green tea leaf extract REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 SENNA senna leaf extract REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 504 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 calciummagnesium-zinc calcium/magnesium/zinc REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 magnesium magnesium amino acid chelate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 centrum silver,complete 50+,spectravite adult 50+,adults' 50+ daily formula,complete senior,century mature,senior tabs,central-vite senior,century,ce ntral-vite,a thru z select,a thru z select 50+ formula,spectravit e advanced form,sentry senior,certavite seniorantioxidant,abc plus,complete multivitamin,cent ury mature formula multivitamin with minerals/folic acid/lycopene/lutein,multivita min w-minerals/folic acid/lycopene/lutein,multivita min w-minerals/lutein REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 APETIGENPLUS ferrous gluconate/lysine hcl/vit e/vit b cplex with c/zinc REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 vitamin d3 cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 magnesium magnesium amino acid chelate REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 505 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name calcium citrate/cholecalciferol (vitamin d3) Type of Change Previous Value New Value REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium citratevitamin d 03/31/2016 ezfe 200,pic 200 iron polysaccharide complex REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium 500-vit calcium d3,oyster shell carbonate/cholecalciferol calcium-vit (vitamin d3) d3,oyster shell calcium w-vit d,calcium 500 + vit d,os-cal 500vit d3,oysco 500vit d3,calcium 500 + d,hical,oyst-cal-d 500,os-cal 500+d REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 paricalcitol,zempl paricalcitol ar REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 paricalcitol,zempl paricalcitol ar REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 paricalcitol,zempl paricalcitol ar REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 centrum,vitatrum folic acid/multivit with fe,other mineral,folic acid/multivits w-fe,other min REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 corvite,corvita REMOVE FROM FORMULARY Covered Non-Formulary folic acid/multivitamin,ther and minerals/lycopene/lutein BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 506 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 ICAPS,CARDIOT riboflavin/beta-carotene(a) EK w-c and e/lutein/zeaxanthin/min,ribofl avin/beta-carotene(a) w-c & e/lutein/zeaxanthin/min,vit c/vite ac/pyridox hcl/fa/vit b12/arginine hcl/pepper ext REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 risacal-d,calvite p&d,dical-d calcium phosphate, dibasic/cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 wal-mucil plus psyllium husk/calcium calcium,walcarbonate mucil,fiber plus calcium,metamuc il plus calcium REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium carbonate calcium carbonate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 SENNA PROMPT sennosides/psyllium husk,sennosides/psyllium REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 theragran-m advanced 50 plus,essential woman 50+,therapeuticm,essential 50+ folic acid/multivitamin wminerals/lutein,folic acid/multivitamin with minerals/lutein REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 COMPLEX B-50 calcium carbonate/vitamin b complex/folic acid REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 advanced am/pm,encora REMOVE FROM FORMULARY Covered Non-Formulary omega-3 fatty acids/calcium carb/vitamin d3/fa/mv cmb 13,omega-3 fatty acids/ca carbonate/vitamin d3/fa/mv cmb 13 BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 507 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 ESSENTIAL multivitamin with MAN,ESSENTIA minerals/folic L MAN 50+ acid/lycopene/lutein REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 tri-vita,tripediatric multivitamin vitamin,trivitamin a,c,and d3 no.21,pediatric multivitamins a,c,& d3 no.21 REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 FIBER-STAT fructooligosaccharides/malto dextrin REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium,viactiv,ca calcium lcium soft carbonate/cholecalciferol (vit chew,soft chews d3)/phytonadione calcium REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 certavitelutein,certa plus,certagen REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium 500 + vit calcium d carbonate/cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 gavilyte-n,peg sodium chloride/sodium 3350bicarbonate/potassium electrolyte,peg- chloride/peg 3350 with flavor packs,trilyte with flavor packets,nulytely with flavor packs,nulytely REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 fabb,tl gard cyanocobalamin/folic rx,folgard acid/pyridoxine rx,foleve plus,virtgard,allanfol rx REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 DIALYVITE REMOVE FROM FORMULARY Covered Non-Formulary folic acid/multivit with fe,other mineral/lutein,folic acid/multivits w-fe,other min/lutein folic acid/vitamin b comp and c BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 508 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 calcium citrate malate with d calcium citrate malate/cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 slow fe,slow release iron ferrous sulfate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 vitamin e vitamin e (dl-alpha tocopheryl acetate) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 FOSRENOL lanthanum carbonate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 FOSRENOL lanthanum carbonate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ivites rx,nephplex vitamin b complx no.3/folic rx acid/ascorbic acid/biotin/znox REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 fiber,fiber inulin/sorbitol supplement,weig ht management fiber REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 centrum,multivital folic ,a thru acid/multivit,calcium,iron,&ot z,centravites her mins/lycopene/lutein,folic acid/multivit,calcium,iron,oth er mins/lycopene/lutein,folic acid/multivits w-fe,other min REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 TANDEM DUAL ACTION ferrous fumarate/iron polysaccharide complex REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 FERAHEME ferumoxytol REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 laxative,sennasennosides extra,senokotxtra REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 509 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 vitamin d3,just d,d-vita,d-vi-sol cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 l-methyl-mc nac,cerefolin nac,lmethylfolatemecobalaminnac,enfolastn,metafolbic plus,triveen-cf nac,alz-nac acetylcysteine/mecobalamin /levomefolate calcium REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 AMITIZA lubiprostone REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 M.V.I. ADULT mvi, adult no.1 with vit k REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 CALCIONATE calcium glubionate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 dualvit plus,tandem plus,se-tan plus,purevit dualfe plus iron fumarate-iron polysacchar/folic acid/mv comb18,iron fumarate-iron polysacch cplex/folic acid/multivit no.18 REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 hectorol,doxercal doxercalciferol ciferol REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 best fiber,natural wheat dextrin fiber,children's benefiber,benefib er,total fiber REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 b-complex with vit c,b complex with vitamin c REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 super b complex vitamin b complex with vitamin c combination no.4 REMOVE FROM FORMULARY Covered Non-Formulary vitamin b complex & vit c no.3,vitamin b complex with vitamin c combination no.3 BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 510 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 calcium citratecalcium vitamin d,citracal- citrate/cholecalciferol vitamin d,calcium (vitamin d3) citrate-vitamin d3 REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 BALANCED B100 vit b complex 100 combo no.3/herbal drugs REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 RENVELA sevelamer carbonate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 RENVELA sevelamer carbonate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 MG-PLUSPROTEIN magnesium oxide/magnesium amino acid chelate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 metamucil fiber psyllium husk/aspartame singles,natural fiber supplement REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 vitamin e,natural vitamin e mixed vitamin e REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 vitamin e,natural vitamin e,vitamin e mixed vitamin e,formula e REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 FEM-CAL CITRATE calcium citrate/magnesium ox/vit d2/manganese/boron/silica REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 FREEDAVITE multivitamin with minerals/ferrous fumarate/folic acid REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 GAVISCON magnesium trisilicate/al hydrox/sod bicarb/alginic acid REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 511 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 OSTEOPORETICAL calcium carbonate/cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 magnesium gluconate magnesium gluconate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 SUPERVITE EC folic acid/multivitamin wminerals,multivitamins with min no.21/folic acid REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 CALCET REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 CITRACAL,CITR calcium citrate/magnesium ACAL-VIT D + oxide/vitamin MAGNESIUM d3/pyridoxine/min,calcium cit/magnesium/d3/zinc ox/copper gluc/manganese/boron REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 RABANO YODADO vitamin b complex no.12/niacinamide REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 FERRACTIV IRON iron amino acid chelate/cyanocobalamin/foli c acid REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 vitamin e vitamin e acetate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 PEDIA-LAX glycerin REMOVE FROM FORMULARY Covered Non-Formulary calcium citrate/cholecalciferol (vitamin d3) BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 512 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name 03/31/2016 century energy metabolism,spect ravite energy metabolism,centr al-vite energy,a thru z active performance,cent ral-vite performance,cent rum performance,a thru z advantage 03/31/2016 Generic Name Type of Change Previous Value New Value REMOVE FROM FORMULARY Covered Non-Formulary centrum ultra multivits w-ca, other men's,central-vite min/iron/folic acid/lycopene men's under 50,spectravite men's,century ultimate men's,complete men,a thru z,centrum men REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 PEDIA-LAX REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 l-methyl-b6-b12,l- mecobalamin/levomefolate mefolate-pyridox- calcium/pyridoxal phosphate mecobalamin,dul eek-met new,metanx,folta nx,neurpathb,vitacirc-b REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 CITRACAL D + calcium carbonate and HEART HEALTH citrate/vitamin d3/phytosterol REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium lactate REMOVE FROM FORMULARY Covered Non-Formulary multivitamin-minerals/iron fumarate/folic acid/panax ginseng,multivitamins with minerals/iron/folic acid/korean ginseng magnesium hydroxide calcium lactate BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 513 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 bacmin,megavite multivitamins w-minerals rx combination no.20/iron/folic acid REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium gluconate calcium gluconate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 dewee's carminative magnesium carbonate/asafetida REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 one daily multivitamin with women's minerals/folic acid/ginkgo 50+,daily leaf extract multiple,women's 50+ daily formula,one daily men's 50+,one daily,one daily for women 50+ adv REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 DIALYVITE 800- folic acid/vitamin b comp ULTRA D and c/zinc/vitamin d3 REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium citrate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 PARVA-CAL 500 calcium carbonate,calcium gluconate/ergocalciferol (vit d2) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ULTRA FREEDA multivits, ca, minerals/iron fumarate/folic acid REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 certavitemultivitamin with antioxidant,cerovi minerals/ferrous gluconate te,centrum,multivi tamins with minerals,centram -care,centamin REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 QUINTABS-M REMOVE FROM FORMULARY Covered Non-Formulary calcium citrate multivits, ca, minerals/iron fumarate/folic acid BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 514 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 calcium carbonate calcium carbonate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 cal-mint,calcium carbonate calcium carbonate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ULTRA FREEDA multivitamin with calcium, minerals/folic acid REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ferrous fumarate ferrous fumarate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 DECUBI VITE multivitamin/folic acid/zinc sulfate/ascorbic acid REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 fe 90 plus,ferralet iron carbonyl,gluc/folic 90,focalgin acid/vit b12/vit c/docusate dss,natalvirt flt sodium,iron,carbonyl/folic acid/vitamin b12/vitamin c/docusate na REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 bifera rx,hemetab iron polysacchar complx/iron heme polypeptide/folic acid/b12 REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 BIOCAL calcium carbonate/vit d3/magnesium oxide/folic acid/vit k REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium lactate calcium lactate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 vitamins a-d-e vitamin a palmitate/betacarotene/vit d2/vit e/selenium REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium amino acid chelate calcium amino acid chelate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 coral calcium calcium carbonate/cholecalciferol/ma gnesium amino ac chelate REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 515 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 CAL-MAG calcium carbonate/magnesium oxide, carbonate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 diabetes health formula folic acid/multivitamin with minerals/lutein REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 multivital multivitamin with platinum,spectrav minerals/folic ite senior,sentry acid/lycopene/lutein senior,complete multi 50+,a thru z select,vitrum 50+ senior,century mature REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 COLYTE WITH peg 3350/sod sulf/sod FLAVOR PACKS bicarbonate/sod chloride/potassium chl REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 halflytelybisacodyl,gavilyte -h and bisacodyl,pegprep bisacodyl/sodium chlor/sodium bicarb/potassium chl/peg 3350 REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 BIO-35 mv,ca,min/ferrous fumarate/fa/lutein/lycopene/ herbal no.175 REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 SUPREP sodium sulfate/potassium sulfate/magnesium sulfate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 SLOW-MAG magnesium chloride REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 METAMUCIL,ME psyllium husk/aspartame TAMUCIL SUGAR FREE REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 516 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 multivitamin,com multivitamin with plete minerals/ferrous fumarate multivitaminmineral REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 PREPOPIK sodium picosulfate/magnesium oxide/citric acid REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 easy fiber wheat dextrin/calcium carbonate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 PROTECT IRON multivitamin-minerals no.24/iron polysaccharide complex/fa REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 UPCAL D calcium citrate/cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 UPCAL D calcium citrate/cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 AQUADEKS multivitamin with min no.51/folic acid/phytonadione/ubidecar REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 DIALYVITE SUPREME D multivitamins with min no.25/folic acid/vitamin d3 REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 mega multi,mega multivit w-ca, min/iron multivitamin chelate/fa/lutein/herbal #179 REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 mega multi,mega multivitamin with multivitamin minerals/folic acid/lycop/lut/herbal 178 REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 theragran-m premier 50 plus REMOVE FROM FORMULARY Covered Non-Formulary multivitamin w-minerals/folic acid/co q10/lycopene/lutein BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 517 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 IROSPAN iron bisgl,ps cmplx/folic acid/vit b,c no.12/succinic acid REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium + d calcium carbonate/cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium in premium chocolate calcium carbonate/magnesium oxide/cholecalciferol (vit d3) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 one daily diet support multivit,calcium,min/iron/folic acid/epigallocatechin/caff REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 children's calcium calcium phosphate gummies tribasic/ergocalciferol (vitamin d2) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium 600 + vitamin d,liquid calcium 600-vit d3,calcium + vit d3 calcium carbonate/cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 NEPHROCAPS QT vitamin b complex & vitamin c no.13/folic acid/vitamin d3,vitamin b complex with vitamin c no.13/folic acid/vitamin d3 REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 STRESS BCOMPLEX vitamin b comp w-c/fa/zinc sulfate/copper oxide/vitamin e REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 518 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 spectravite ultra multivitamin with women's,central- minerals/ferrous vite women's fumarat/folic acid/lutein mature,ultimate women's complete 50+,centrum silver women,century ultimate women's REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 VENOFER REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 slow release iron ferrous sulfate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 slow release iron,ferrous sulfate ferrous sulfate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 VENOFER iron sucrose complex REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 nulecit,sod ferric sodium ferric gluconate gluconate complex in sucrose complex,ferrlecit REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium 1000 + d3 calcium carbonate/cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 iron ferrous gluconate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 liquid calcium-vit calcium d carbonate/cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 CALCET PETITES REMOVE FROM FORMULARY Covered Non-Formulary iron sucrose complex calcium carbonate, calcium lactate-cholecalciferol (vit d3) BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 519 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 PHOSLYRA calcium acetate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 IRONUP iron polysaccharide complex REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 iron,slow release ferrous sulfate, dried iron REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 oyster shell calciummagnesium calcium carbonate/magnesium oxide REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calciummagnesium-zinc calcium/magnesium/zinc REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 thera-tabs multivits, ca, minerals/iron m,women's daily fumarate/folic acid REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 stress formula with iron,vitamin b complex REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 THERACAL,PRO calcium cit/vit d3/vit k/mag STEON ox/strontium cit/sodium borate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 b complex with vitamin c thiamine m.nit/riboflavin/niacin/ca pantothenate/b6/b12/c/fa REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 THERACAL calcium cit/vit d3/vit k/mag ox/strontium cit/sodium borate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 biopetit,apetex,ap vitamin b complex/lysine etigen REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 BLADDER 2.2 REMOVE FROM FORMULARY Covered Non-Formulary iron/multivits,stress formula,vit b complex/vit c/folic acid/ferrous fumarate/vit e acet multivitamin with minerals/folic acid/lycopene/boron BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 520 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 stress formula energy vit b comp c/ferrous fumarate/folic acid/vit e/amino acid 16 REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 k-pax immune support multivit with min/iron picolinate/fa/calcium/d3/ami no acid REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 one-a-day multivits, ca, minerals/iron women's,women' fumarate/folic acid s one daily,central-vite women's under 50,daily multiple,women's daily formula,one daily women's REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 cal mag zinc + calcium carbonate/vitamin d3,cal mag zinc + d3/magnesium oxide/zinc d oxide REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 b-complex vitamin b comp and c/calcium carbonate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 fiber gummies,fiber select gummies inulin/chromium picolinate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ferrous gluconate ferrous gluconate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 bp vit 3 omegaplus,animi-3 with 3/dha/epa/d3/b12/folic vitamin d,animi-3 acid/pyridox hcl/phytosterol REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 UDAMIN SP multivitamins with min no.9/folic acid/saw palmetto extract REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ENEMA sodium phosphate,monobasic/sodiu m phosphate,dibasic REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 521 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value multivitamin with min no.52/folic acid/phytonadione/ubidecar REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 AQUADEKS 03/31/2016 calcium + vitamin calcium carbonate and d3,citracal + citrate/cholecalciferol (vit d3) d,calcium + d3 REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 SLOW RELEASE ferrous sulfate, dried IRON REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 COLOX psyllium husk/laxative combination no.1 REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 fiber therapy,soluble fiber therapy methylcellulose (with sugar) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 LOCALNESIUM calcium carbonate and citrate/magnesium citrate, glycinate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 os-cal 500-vit d3,calcium 500vit d3 calcium carbonate/cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 enemeez,vacuant docusate plus sodium/benzocaine REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 enemeez,vacuant docusate sodium REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 lactulose lactulose REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 PRORENAL vit b cplx with c/ferrous fumarate/folic acid/vit d3/zinc ox REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 MAXARON FORTE iron glycin,sulfumu/vitc/b12/methyltetrahy drofolate calcium REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 522 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 diabetes health support multivitamin with calcium &other minerals/fa/bioflavonoids#4 REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 lactulose lactulose REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 NICOMIDE methyltetrahydrofolate glucosamine/niacinamide/cu pric &zn ox REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 women's multivitamin with multivitamin,daily minerals/folic acid gummies,adult multivitamin gummies,one-aday vitacraves,one daily gummy vites,men's multivitamin,onea-day vitacraves immunity,one-aday vitacraves sour,one-a-day women vitacraves,one-aday men vitacraves,men's daily gummies,women s daily gummies,spectra vite adult,adult multi gummies,adult one daily gummies REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 523 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 one-a-day men's multivitamins w50 plus,men's minerals/folic 50+ daily formula acid/lycopene/ginkgo leaf xt REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 one daily women's health,one daily women's multivits, ca, minerals/iron fumarate/folic acid REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 INFUVITE ADULT mvi, adult no.4 with vit k REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 CARDIAMIN multivitamin with min/folic acid/d3/omega3/dha/epa/fish oil REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 vitamin e vitamin e REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 LOCALNESIUM- calcium C carbonate/magnesium oxide/ascorbic acid REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ONE-A-DAY VITACRAVES OMEGA-3 multivitamin/folic acid/docosahexanoic acid REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 GLYCERIN LAXATIVE glycerin REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 one-a-day multivit,ca,min/ferrous women's,women' fumarate/folic s active acid/guarana/caffeine REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium phosphate calcium phosphate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 doxercalciferol doxercalciferol REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 PRORENAL QD multivitamin with iron,other min/fa/d3/om-3/dha/epa/fish oil REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 524 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 senna leaves senna,senna leaf REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 brewer's yeast,yeast yeast, dried (saccharomyces cerevisiae),yeast REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 vitamin e vitamin e mixed REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 vitamin e vitamin e mixed REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 men's one multivitamin with daily,one-a-day minerals/folic acid/lycopene men's,men's daily formula,one daily men's REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 century ultimate multivitamin with men's,centrum minerals/folic silver ultra acid/lycopene/lutein men's,ultimate men's complete 50+,spectravite ultra men 50+,a thru z select,spectravite ultra men's REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 hair, skin and nails multivit, ca, minerals/ferrous gluconate/folic acid/biotin REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ADVANCED CALCIUM calcium citrate/minerals/vitamin d3/vit k2/silicon dioxide REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ONE-A-DAY MENOPAUSE FORMULA multivitamin with calcium, mineral/folic acid/soy isoflavone REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ONE-A-DAY WOMEN'S HEALTHY SKIN multivitamin with calcium, minerals/iron/folic acid/lutein REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 525 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name calcium carbonate/cholecalciferol (vitamin d3) Type of Change Previous Value New Value REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 CAL-QUICK 03/31/2016 one daily multivit,ca,min/ferrous energy,one-a-day fumarate/folic energy acid/guarana/caffeine REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ONE-A-DAY WOMEN'S PETITES multivits, ca, minerals/iron fumarate/folic acid REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 antacid calcium calcium carbonate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 vitamin e vitamin e acid succinate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 vitamin e vitamin e acid succinate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 one daily multivitamin with folic acid multivitamin,one daily essential,quintab s REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 MONOCAPS multivitamin with minerals/ferrous fumarate/folic acid REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 FOSRENOL lanthanum carbonate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 FOSRENOL lanthanum carbonate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 QUIN B STRONG vitamin b comp and c/folic acid/zinc REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 psyllium seed psyllium husk REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 526 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value calcium phosphate, tribasic/cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 citracal + d3,calcium 03/31/2016 adult multivitamin folic acid/multivitamin with gummies,multiminerals/lutein vitamin REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 one-a-day multivitamin with women's minerals/folic acid/calcium 50+,women's 50+ carb/vit k1 daily formula REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 balanced b complex-vit c REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 PARVA-CAL 250 calcium carbonate,calcium gluconate/ergocalciferol (vit d2) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ALKA-SELTZER sodium bicarbonate/sodium HEARTBURN citrate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 vitamin e vitamin e mixed REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 MULTI-DELYN multivitamin/ferrous gluconate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 stress formula with iron vit b complex/vit c/folic acid/ferrous sulfate/vit e acet REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 vitamin eoil,vitamin e vitamin e (dl-alpha tocopheryl acetate) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 PARVLEX ferrous fumarate/folic acid/vitamin b comp and c/minerals REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 NOVAFERRUM iron polysaccharide complex REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 HYFIBER WITH FOS fructooligosaccharides/polyd extrose REMOVE FROM FORMULARY Covered Non-Formulary vitamin b complex with vitamin c combination no.3 BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 527 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 FOLGARD cholecalciferol/folic acid/riboflavin/pyridoxine hcl/vit b12 REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 NOVAFERRUM 125 iron polysaccharide complex/cholecalciferol (vit d3) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 NOVAFERRUM 50 iron polysaccharide complex REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium 600-vit d3,caltrate 600 plus d3,centrum pro nutrients calcium carbonate/cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 CENTRUM SPECIALIST ENERGY multivitamin-minerals/iron fumarate/fa/vit k/korean ginseng REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 E-Z-GAS II simethicone/sodium bicarbonate/citric acid REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 magnesium citrate magnesium citrate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 SUPER multivitamin with iron,other MULTIPLE-LOW min/fa/dietary supp comb. IRON no.24 REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 DIABETES HEALTH PACK REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 poly-vitamin,poly- pediatric multivitamin no.20 vita REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium 600+d plus,calcium 600+d3+minerals ,caltrate 600+d plus REMOVE FROM FORMULARY Covered Non-Formulary mv,ca,mn/k/omega-3/vit d3/mag/c/alip acid/green tea/chromium calcium carbonate/vit d3/mag ox/zinc/copper/manganese/ boron BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 528 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name calcium carbonate/d3/mag #11/zinc/cupric su/manganese/boron Type of Change Previous Value New Value REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 CALTRATE 600+D PLUS 03/31/2016 calcium 500 + vit calcium d,citracal,calcium carbonate/cholecalciferol (vit + d,calcium soft d3)/phytonadione chew REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 iron chews,icar iron,carbonyl REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 mens 50+ advanced one daily,one-a-day men's 50 plus multivitamin with minerals/folic acid/phytonadione/lycopene REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ONE-A-DAY WOMEN'S multivitamin-minerals/iron fum/folic acid/calcium carb/vit k REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 MAGONATE magnesium carbonate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ferate,iron ferrous gluconate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 VIRT-VITE PLUS folic acid/vitamin b complex with vitamin c no.17 REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 THERANATAL LACTATION SUPPORT multivit with min/iron/folic acid/k/d3/choline/dha/fish oil REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 SOLO multivitamin with minerals/folic acid/phytonadione REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 CALMAG THINS calcium carbonate and citrate/magnesium oxide REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 529 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 FUSION PLUS iron fum,polysac comp/folic acid/vit b compc no.18/l. casei REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 PROCERV HP multivit w-min/iron fumarate/folic acid/vit k/green tea xt REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 fiber choice,child's fiber select gummies inulin REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 SUCLEAR polyethylene glycol 3350/bowel prep #2,two part prep REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 MULTI FOR HER multivit with calciummins/iron fumarate/folic acid/vit k REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 metanx,foltanx rf,l-methylfolate ca p-5-p mecbl,levomefolpyridoxal-mecalgal REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 lmthf-pyridoxine- cyanocobalamin/levomefolat cyanocobal,cyan e calcium/pyridoxine hcl ocobal-levomefpyridoxine,folbic rf,foltx REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ferrous sulfate,ferosul ferrous sulfate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 IRON 21/7 iron bis-glycinate chelate/fa/vit c/b12/cathr/succinic acid REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 VITRON-C iron,carbonyl/ascorbic acid REMOVE FROM FORMULARY Covered Non-Formulary levomefolate ca/pyridoxal phos/mecobalamin/schiz. algal oil BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 530 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name multivitamin with minerals/folic acid/phytonadione Type of Change Previous Value New Value REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 trueplus multivitamin 03/31/2016 metafolbic plus levomefolate rf,levomefolaca/acetylcysteine/mecobala nac-mecobalm- min/schiz. algal oil algal,lmethylfolatemecobalaminnac,cerefolin nac,levomefolatenac-mecobalalgal REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 PODIAPN pyridoxal phos/methyltetrahydrofolate gluc/mecobalamin/ala REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 FERIVA iron bisgly&carbonyl/folic acid/vit c/cyanocobalamin/biotin REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 OXI-FREEDA multivitamin with minerals/glutathione/cystein e REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 FIBER-STAT fructooligosaccharides/polyd extrose REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ACTIVE FE iron,carbonyl/folic acid/multivitamin with minerals REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium adult calcium phosphate, tribasic/cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 KONSYL psyllium husk REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 INJECTAFER ferric carboxymaltose REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 531 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name multivit with calciummins/iron fumarate/folic acid/vit k Type of Change Previous Value New Value REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 OPTISOURCE 03/31/2016 VITACEL,BIOCE multivitamin with L minerals/folic acid/lycopene/lutein REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 aminobenzoate potassium aminobenzoate potassium,potaba REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 DOCUSOL PLUS docusate sodium/benzocaine REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 CORVITE FE iron,carbonyl/methyltetrahyd rofolate gluc,fa/mv, min no.40 REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 biotin biotin REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 FERRETTS iron,carbonyl REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 MACULAR VITAMIN multivitamin with minerals/folic acid/lutein/zeaxanthin REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 CORVITE 150 iron,carbonyl/methyltetrahyd rofolate gluc,fa/mv, min no.41 REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 CALTRATE 600 +D calcium carbonate/cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 CALCI-MAX calcium/fa/b complex/d3/e/citrus bioflavonoids/soy extract REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 BENEFIBER wheat dextrin REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 532 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 NEPHRONEX-SL vitamin b complex with vitamin c no.19/folic acid/vitamin d3 REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 IRO-PLEX iron ps/vit c/b12/b6/e acet/fa/intrinsic factor/senna leaf REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ABATRON AF iron,carb/fa/vit c/vit e ac/b12/biotin/cupric sulf/docusate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 DOCUSOL KIDS docusate sodium REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 vitamin e vitamin e acetate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 KONSYL psyllium husk/aspartame REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 VELPHORO sucroferric oxyhydroxide REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 multivitaminsa,b,d,e,k,zn multivitamins with min no.44/cholecalciferol (vit d3)/vit k REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 KONSYL EASY MIX psyllium husk REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 KONSYL FORMULA-D psyllium husk (with dextrose) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 konsyl,metamucil psyllium husk (with sugar) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 DIALYVITE 800 WITH ZINC vitamin b complex & vit c/folic acid/zinc citrate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 DIALYVITE 800 WITH ZINC vitamin b complex & vit c/folic acid/zinc citrate REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 533 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 CYTO B7 biotin REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ABATRON iron ps/fa/vitamin b complex no.16/mag sulfate/zinc sulfate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 FLINTSTONES BONE SUPPORT calcium phosphate, tribasic/cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium 600-d3 plus,calcium 600+d+minerals, calcium 600 + vit d calcium carbonate/vit d3/mag ox/zinc/copper/manganese/ boron REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 PROTECT PLUS multivit-min/methylfolate SO,PROTECT glucos/coenzyme PLUS AF q10/dietary no.26 REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 KONSYL psyllium husk REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium citrate plus calcium cit/magnesium/d3/zinc ox/copper gluc/manganese gluc REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 HAIR, SKIN AND multivitamin with iron,other NAILS minerals/folic acid/biotin REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 BREWER'S YEAST yeast, dried (saccharomyces cerevisiae) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 PROTECT CARDIO AF multivit-min/methylfolate glucos/coenzyme q10/dha/epa/diet27 REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 KONSYL BALANCE psyllium husk/inulin/aspartame REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 534 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name wheat dextrin/lactobacillus acidophilus/aspartame Type of Change Previous Value New Value REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 fiber with probiotic 03/31/2016 HAIR, SKIN AND multivitamin with NAILS minerals/folic acid/biotin REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 B-COMPLEX WITH B-12 thiamine hcl/riboflavin/niacinamide/cy anocobalamin/protease REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 MAXFE iron carb,bg/methylfolate/b12/ma g ascorbate/biotin/zinc/dss REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 OPURITY MULTIVITAMIN iron,carbonyl/folic acid/multivitamin with minerals REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 CALTRATE 600+D3 PLUS MINERALS calcium carb/vit d3/mag ox/zinc/copper/manganese/ mg borate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 BONE ESSENTIALS calcium hydroxyapatite/vitamin d3/vitamin c/vit k2/minerals REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 AURYXIA ferric citrate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 PERFECT IRON iron,carbonyl REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 PROSIGHT vit a/c/e acetate/zinc oxide/sodium selenate/cupric oxide REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 THERAMILL FORTE multivit-min/folic acid/inositol/choline bit/bioflav,citrus REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 FERIVA 21-7 iron asparto gly/folic ac/vitc/b12/zinc/docusate/su ccinic ac REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 535 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 paricalcitol paricalcitol REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 paricalcitol paricalcitol REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 caltrate gummy bites,calcium + vitamin d3 calcium phosphate, tribasic/cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 NICOMIDE levomefolate ca/niacinamide/copper/zinc/ selenium/chromium REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 FUSION iron fumarate-iron polysaccharide combo no.1/vit c/l. casei REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 FERIVA FA iron bisgly,aspart,fumarate/fa#1/ vit c/b12/biotin/copper/dss REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 BEROCCA multivitamin with minerals/folic acid/guarana/caffeine REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 antacid calcium carbonate/magnesium hydroxide REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 DAILY MULTIVITAMIN multivit with minerals/fa/vit k/lycopene/lutein/coenzyme q10 REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ALKA-SELTZER calcium HEARTBURN+G carbonate/simethicone AS REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 FOLINIC-PLUS REMOVE FROM FORMULARY Covered Non-Formulary leucovorin calcium/pyridoxal phosphate/mecobalamin BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 536 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 ALKA-SELTZER potassium bicarbonate/sodium bicarbonate/citric acid REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 DIALYVITE 800 PLUS D vitamin b complex with c/folic acid/cholecalciferol (vit d3) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ONE-A-DAY VITACRAVES ENERGY multivitamin with minerals/folic acid/caffeine REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 oyster shell + calcium d,oyst-calcarbonate/cholecalciferol d,oysco d,oyster (vitamin d3) shell calcium wvit d REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 MEN'S POTENT calcium/vitamin e/folic FORMULA acid/pyridoxine/herbal drugs REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 rolaids,antacid,ac calcium id relief carbonate/magnesium hydroxide REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ZEMPLAR paricalcitol REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium citrate + d,calcium citrate plus calcium citrate/magnesium oxide/vitamin d3/pyridoxine/min REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 NATURAL VEGETABLE LAXATIVE senna/fennel REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calciummagnesium-zinc calcium carbonate/magnesium oxide/copper/zinc oxide REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 HOMOCYSTEIN cyanocobalamin/folic E FORMULA acid/pyridoxine REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 537 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 hectorol,doxercal doxercalciferol ciferol REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium with calcium vitamin d,calcium carbonate/cholecalciferol 600-vit d3,oyster (vitamin d3) shell calcium wvit d,calcium 600 with vitamin d,calcium 600 + vit d,calcarb 600 with vitamin d,super calciumvitamin d REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 prostamen vitamin e acetate/copper/selenium/zn ox/pyg afri/saw palmetto REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 METAMUCIL psyllium seed (with sugar) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 antioxidant,onea-day antioxidant,antiox idant formula beta-carotene(a) w-c & e,beta-carotene(a) w-c & e/minerals,beta-carotene (vit a) with vitamins c and e/minerals REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ocutabs,vision,oc uvite,optivitamins,opticvites,ocumin,eye health plus lutein beta-carotene (vit a) with vitamins c and e/minerals,beta-carotene(a) w-c & e/minerals,betacarotene(a) w-c and e/lutein/minerals REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 vitamin cholecalciferol (vitamin d3,vitamin d,delta d3),ergocalciferol (vitamin d3,vitamin d-400 d2) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 konsyl,natural psyllium seed/aspartame fiber,natural vegetable powder REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 538 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 oyster shell calcium w-vit d calcium carbonate/ergocalciferol (vitamin d2) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 oyster shell calcium w-vit d calcium carbonate/ergocalciferol (vitamin d2) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium 500 + vitamin d calcium carbonate/cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium citratevitamin d calcium citrate/ergocalciferol (vitamin d2) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calciummagnesium-zinc calcium/magnesium/zinc REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 SENILEZOL,I.L.X thiamine/riboflavin/niacin/ca . B-12 pantothenate/vit b6/b12/iron,iron/vitamin b complex/cyanocobalamin/liv er extract REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 APETIGEN vitamin b complex/ferrous PLUS,SUPLEVIT gluconate/zinc oxide/lysine,ferric ammonium citrate/lysine hcl/vitamin b complex/zinc REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ferrogels ferrous fumarate/ascorbic forte,trigels-f acid/cyanocobalamin/folic forte,hematogen acid forte REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 hematogen fa ferrous fumarate/ascorbic acid/cyanocobalamin/folic acid REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 foltrin,tl ferrous fumarate/ascorbic icon,conison,ferot acid/b12-if/folic acid rin,ferocon,ferotri nsic,tricon REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 539 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 folitab 500,fero- ferrous sulfate/ascorbic folic-500,tl-fol 500 acid/folic acid REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ECEE PLUS vitamin e acid succinate/ascorbic acid/mag sulf/zinc sulfate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 i.l.x. b-12,liver with iron ferrous fumarate/liver extract/vitamin b comp wc,ferrous fumarate/liver extract/vitamin b comp and c REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ferrocitef,hematinic with folic acid,hemocyte-f ferrous fumarate/folic acid REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 NEPHRON FA ferrous fumarate/docusate/folic acid/vitamin b comp and c REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 iron with stool softener ferrous fumarate/docusate sodium REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ferrocite plus,hematinic plus ferrous fumarate/folic acid/multivitamins with min no. 15,iron/folic acid/vitamin b comp and c/minerals,iron/folic acid/vitamin b comp wc/minerals REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 protect plus,tyr cooler,biotect plus amino acids/multivits wfe,other min,amino acids/multivits,th w-fe,other min REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ACTICAL calcium carbonate/magnesium oxide/vitamin d2/bioflavonoids REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 540 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 supreme antacid,mylanta supreme antacid,antacid supreme calcium carbonate/magnesium hydroxide REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 GAVISCON magnesium carbonate/aluminum hydroxide/alginic acid REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 antacid,foaming magnesium trisilicate/al antacid,genaton, hydrox/sod bicarb/alginic heartburn acid tablet,antacid tablet REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 mylanta calcium ultra,mylanta,mi- carbonate/magnesium acid ds hydroxide REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 541 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 antacid with simethicone,anta cid,antacidantigas,antacid plus antigas,flanax,antaci d m,liquid antacid,advanced antacidantigas,mylanta, maldroxal,alummag hydroxidesimethicone,comf ort gel,maalox advanced,maalox ,geri-lanta,digel,geri-mox,unilan,milantex,rimox,almacone,m agnesium hydraluminum hydr,rigel,mintox,advan ced antacid,masanti, mag-al plus,maglox,rulox ,mi acid magnesium hydroxide/aluminum hydroxide/simethicone,magn esium hydroxide/aluminum hydroxide REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 antacidmagnesium antigas,antacid ii hydroxide/aluminum with hydroxide/simethicone simethicone,mas anti double strength REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 542 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date 03/31/2016 Brand Name Generic Name Type of Change Previous Value New Value masanti,antacid- magnesium antigas,antacid hydroxide/aluminum maximum hydroxide/simethicone strength,comfort gel,antacid m,antacid extra strength,antacid, antacid with simethicone,maal ox plus extra strength,antacid plus antigas,antacid double strength,liquid antacid,advanced antacidantigas,maalox maximum strength,mylanta, mylanta doublestrength,mylantex doublestrength,mi-acid ii,mylanta maximum strength,almacon e-2,antacid & antigas,mintox maximum strength,gelusil,a ntacid anti-gas double str,mag-al plus xs,antacid ii plus simethicone,ri-gel ii,antacid & gas relief,mi-acid REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 543 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 alamag plus,rimox plus magnesium hydroxide/aluminum hydroxide/simethicone REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 antacid magnesium plus,gelusil,almac hydroxide/aluminum one,alamaghydroxide/simethicone plus,antacid with simethicone,mint ox plus,magalox plus REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 MAG-AL REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 acid gone,antacid magnesium extra carbonate/aluminum strength,heartbur hydroxide,calcium carbonate n antacid,heartburn relief,foaming antacid,gaviscon REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 whole multivitamin with source,women's minerals/herbal drugs biomultiple,men's biomultiple REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ri mag plus,ron acid plus magaldrate/simethicone REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 KONDREMUL mineral oil/carrageenan REMOVE FROM FORMULARY Covered Non-Formulary magnesium hydroxide/aluminum hydroxide BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 544 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 enema,saline sodium enema,phosphat phosphate,monobasic/sodiu e enema,pure & m phosphate,dibasic gentle saline enema,enema disposable,dispo sable enema,curad enema,fleet enema,complete ready-to-use enema REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 oral saline sodium laxative,saline phosphate,monobasic/sodiu laxative,phosphat m phosphate,dibasic e laxative,phosphosoda,walphosphate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 natural psyllium psyllium seed (with fiber,konsyldextrose),psyllium seed d,natural vegetable powder,natural fiber powder,metamuci l,natural vegetable laxative,fiber,met afiber,vegetable laxative,nvp powder,natural fiber,fiber supplement,genfi ber,reguloid REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 545 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 natural fiber psyllium seed (with powder,natural sugar),psyllium psyllium,natural seed/aspartame vegetable powder,fiber smooth,fiber supplement,laxm ar,metafiber,natur al fiber,vegetable laxative,metamuc il ot,metamucil,fiber laxative,reguloid,f iber therapy,genfiber REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 CEO-TWO potassium bitartrate/sodium bicarbonate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 SUPER GINSENG MULTIVITAMIN multivitamin with minerals/ginseng REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 SIDEROL iron/liver extract/vitamin b comp and c/minerals REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 HEMATRON ferric ammonium citrate/lysine/vitamin b complex/folic acid REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calphron,calcium calcium acetate acetate,eliphos REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 kelp-lecithin-vit b- lecithin/pyridoxine/kelp 6 REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ARKALIOX sulbutiamine REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 NUTRIVIT iron/lysine/vitamin b complex/folic acid REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 546 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 kelp-lecithin-vit b- lecithin/pyridoxine/kelp 6,kelp-lecithin-b6-vinegar REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 KONSYL psyllium husk/aspartame REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 polyethylene polyethylene glycol 3350 glycol 3350,smoothlax,c learlax,laxative peg 3350,gavilax,pure lax,miralax,health ylax REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 miralax,polyethyl polyethylene glycol 3350 ene glycol 3350,laxa clear,clearlax,sm oothlax,laxative peg 3350,polyethylen e glycol,glycolax,du lcolax balance,powderla x,gavilax,gentlela x,peg3350,purela x REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 VENOFER REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium,chewable calcium calcium carbonate/cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Covered Non-Formulary iron sucrose complex BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 547 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 b-complex vitamin b complex/folic acid 100,vitamin b100 complex,vitamin b complex,kobee,vi tamin b-50 complex,super quints,balanced b-100,super b maxi complex,bcomplex REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium citrate vitamin d,calcium citrate with d,citracal + d,calcium citrate plus,calcium citrate-vitamin d3 calcium citrate/cholecalciferol (vitamin d3),calcium citrate/ergocalciferol (vitamin d2) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium citrate calcium citrate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium 600 with calcium soy,calcium 600 carbonate/ergocalciferol (vit plus soy d2)/soybean REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium + vit d calcium carbonate/cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 magnesium magnesium oxide REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 vitamin e vitamin e acid succinate REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 548 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 virt-vite,folic acid- cyanocobalamin/folic cyancobalacid/pyridoxine pyridoxin,nufol,fol nate,airavite,folbe e,av-vite fb REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ferrous sulfate,high potency iron ferrous sulfate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium with boron calcium carbonate/boron gluconate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 wee care,icar iron,carbonyl REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 MAGNEBIND 400 RX calcium carbonate/magnesium carbonate/folic acid REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 mag64,magnesiu magnesium chloride m dr,mag delay REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 dexfol,folbee plus folic acid/vitamin b comp wc,folic acid/vitamin b comp and c REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 vitamin d3,vitamin d cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 vitamin d3,vitamin d cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 vitamin d3,dialyvite vitamin d cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 stress formula vitamin b complex/minerals REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 MEDTYCHOLL-B vitamin b complex/liver COMPLEX Wextract LIVER REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 549 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 super b-complex b complex with vitamin c & c,superplex-t,bcomplex plus vitamin c,farbee w-c,total b with c,vitamin bcomplex with vit c,high potency b,surbex-t,bcomplex with c,b complex-vitamin c,surbex wc,super b complex-vitamin c,glutofac,bec with zinc,vitabee w-c,b-complex with vitamin c,vita-bee with c,vitamin b&c,vitamin b complex-c,thex forte REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 vitamin bcomplex & c,stress b-100 with vitamin c b complex with vitamin c REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 super b with vit c,vitamin bcomplex with vit c,super b complex with c,support-500 b complex with vitamin c REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 550 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date 03/31/2016 Brand Name Generic Name vitamin b vitamin b complex complex,hi b complex,b complex,super b50 complex,super b complex Type of Change Previous Value New Value REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 551 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name 03/31/2016 vitamin b complex,balance d b-50,balance b50,bal b100,varidin,balan ced b-100,b complete,ultra b100 complex,natural bcomplex,natural b-100 complex,super b50 complex plus,bal b50,stress b,b complex,b complex with b12,super b complex-b12,b50 balanced,vitamin b-100 complex,balance b-100,b complex # 1,balanced b150,bcomplex,natural b-100,hi b complex,b-100 complex,b-50 complex,better b complex,vit balanced b100,balanced b complex,b50,super quints Generic Name vitamin b complex,vit b2/niacinamide/pyridoxine hcl/cyanocobalamin/dpanthenol,folic acid/vitamin b comp w-c Type of Change Previous Value New Value REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 552 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 balanced bvitamin b complex 50,balanced b100,balanced b150,b complex,b100 balanced,ultra b100 complex,vitamin b-100 complex,poten b150,complex b100,b-50 complex REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 aquavit-e,aquasol vitamin e e,vitamin e REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 vitamin e,vitamin vitamin e,vitamin e e natural blend acetate,vitamin e mixed REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 vitamin e vitamin e REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 vitamin e,natural vitamin e,vitamin e acetate vitamin e REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 vitamin e vitamin e acetate,vitamin e,vitamin e mixed REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 vitamin e vitamin e,vitamin e acetate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 wheat germ oil wheat germ oil REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 wheat germ oil wheat germ oil REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 biotin biotin REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 biotin biotin REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 553 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 biotin biotin REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 biotin biotin REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 vitamin a and d vitamins a and d REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 fe c,icar-c,iron 100-vitamin c iron,carbonyl/ascorbic acid REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 alba-lybe lysine hcl/vitamin b complex REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 foltabs 800,folgard cyanocobalamin/folic acid/pyridoxine REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 554 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date 03/31/2016 Brand Name Generic Name one multivitamin,iron/vitamin b daily,essential complex/minerals one daily,daily multiple vitamin,one daily multivitamin,once daily,central vite,one daily essential,multivita mins,multiple vitamins,high potency multivitamin,daily vite,one daily vitamin,onetablet-daily,men's multi-vitamin,daily vitamin formula,unidaily,daily diet support,daily multivitamin,centr al-vite hp,one-aday essential,natural rda multivitamin,daily value,multivitamin daily,tab a vite,vitamins for hair,multi-day vitamins,pharmac ist favorite multivite,super multivitamin,optivi te p.m.t.,multivitami ns hi-po,mega multivitamin,tab- Type of Change Previous Value New Value REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 555 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value a-vite,daily vitamin,multiple vitamins daily,essential balance,super nu-thera 03/31/2016 thera,therapeutic, multivitamins,therapeutic,mu therems,oncovite, ltivitamin,therapeutic therapeutic multivitamin,thera -tabs REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 chewable multi multivitamin vitamin,chewable -vite REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 multivitamins multivitamin REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 super numultivitamin thera,multidelyn,vitamin,ther a vite,daily vitamin,vimar,my favorite multiple REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 thera,kenwood multivitamins,therapeutic,mu therapeutic,thera ltivitamin,therapeutic vite,thera-plus REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 556 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 hair, skin and multivitamin with minerals nails,multivitamin s with minerals,hair, skin & nails,mega vite 75,daily multi carb balance,one daily complete,mega multi w-chelated minerals,vision,m ultiple vitamin,optigen,one tablet daily wminerals,icaps plus,sclerex,card enz,hyalex,ragus, daily vitamin formulaminerals,beezee,one daily,mega multivitamin with mineral,one daily plus minerals,taba-viteminerals,one daily energy,onea-day maximum formula,antioxida nt vitamin,one daily active,vigomar forte,men's one daily REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 totalday multiple REMOVE FROM FORMULARY Covered Non-Formulary multivitamin with minerals BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 557 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 high potency multivitamins,ther wvitaminminerals,multivitamin,therap minerals,vitamin eutic with minerals and minerals,super high vitaminsminerals,super theravitem,therapeutic vitaminminerals,therape utic m,therapeutic vitamin wminerals,therade x-m REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 multivitamins with multivitamin with minerals minerals,myvitalif e,theramill forte REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 multivitamins with multivitamin,therapeutic with minerals minerals,multivitamins,ther hp,theramill w-minerals forte,therapeutic vitamin & mineral REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 apatate multivitamin with minerals forte,biosupp,sup port REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 clusimar,biovol REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 megastress wmultivits,stress c,stress formula,multivitamin,stress formula,stress formula 600,stress,cefol,s tress 500,vistress,stress-c REMOVE FROM FORMULARY Covered Non-Formulary multivitamin with minerals BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 558 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 stress formula + zinc,stress formula with zinc,stress b with zinc,stress with zinc,stress-600 with zinc,surbex 750 with zinc,vistress with zinc,stress 500 plus zinc multivits,stress formula/zinc,multivitamin,str ess formula/zinc,vitamin b complex/minerals REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 stress with iron/multivits,stress iron,stress formula,iron/multivitamin,str formula with ess formula iron,stress b with iron REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 unicomplexmultivitamin with iron and m,century,pms other minerals multivitaminminerals,multilex, super multiple,compete, calcet plus,certagen silver,myamulti,m yadec,generixt,central-vite select,super vitamins,my-amulti,unicap m,unicap-t REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 559 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 theramultivits,th w-fe,other m,therapeutic min,multivit,th iron,other min m,multilex-t-m with minerals,high potency vitaminminerals,complet e multivitamin,spec travite plus REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 superior 35 multivitamin with iron and other minerals REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 multiple vitamins multivit with calcium, iron, for women,one and other minerals daily with calciumiron,women's bone health,multivitami ns w-calciumiron,ultimate teen REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 centralvite,centravite,century,spect ravite,centamin,c entravites REMOVE FROM FORMULARY Covered Non-Formulary multivitamin with minerals,multivits wiron,hematinic,multivitamin with iron,hematinic BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 560 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 multivitamins with multivitamins with iron,one daily iron,multivitamin with iron plus iron,one daily with iron,daily vitamin + iron,daily vite with iron,daily vitamin with iron,tab-a-vite with iron,one-tabdaily with iron,uni-daily with iron,hair vitamin,daily multivitamin with iron,one daily multivitamin REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 SUPER CALMAG REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 magnesium magnesium gluconate gluconate,magon ate,mag-g REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 fiber laxative psyllium seed (with sugar) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 fe-tinic 150,niferex150,rexavite 150,ferrex 150 plus iron asp gly & ps cmplx/ascorb calcium/cathr/succinic acid,iron polysaccharides complex,ferrous bisglycinate chelate/fe ps cmplx/vit c/ca-threonate,iron asp gly,ps cmplx/ascorb calcium/ca-thr/succinic acid REMOVE FROM FORMULARY Covered Non-Formulary calcium carbonate/magnesium oxide BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 561 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 niferex-150 forte,ferroflex 150 forte,iron ag-psasc-b12-fa-thresuc,triferex 150 forte,rexavite 150 forte,ferrex 150 forte plus,fe-tinic 150 forte 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 03/31/2016 trimagen fa,multigen folic,ferrovite fa,chromagen fa iron asp gly/ascorb.cal/vit b12/fa/ca-threonte/succinic acid REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 anemagen,vitage iron aspgly/ascorb.cal/vit n b12/calcium advance,chroma thr/succ.acid/stomach gen,mv-iron-ascb12-thre-sucstom,multigen,tri magen,ferrovite REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 vitagen forte,anemagen forte,chromagen forte,mv-iron fumasp-asc-b12-fasuc,multigen plus,ferrovite forte,trimagen forte iron fumarte &asp gly/ascorb.cal/vit b12/fa/cathr/succ.acid,iron fum,ag/ascorb.calcium/b12/f olic acid/calcium/succ.acid REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 MULTICHEW multivits, iron, minerals combo no #4, folic acid REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 562 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 phosphate sodium laxative,preparati phosphate,monobasic/sodiu on cleansing,oral m phosphate,dibasic saline laxative,oral saline laxative kit,fleet phosphosoda REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 MOVIPREP REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ferrous gluconate ferrous gluconate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 MEN'S DAILY FORMULA multivitamin with minerals/folic acid/lycopene REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 vita s multivits, iron, minerals forte,strovite forte combo no #5, folic acid,multivits, ferrous gluconate, minerals combo no.9,folic acid REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 milk of magnesia magnesium hydroxide REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 vp-vite rx,renavitamin b complx no.3/folic vite rx,nephroacid/ascorbic acid/biotin vite rx,vol-care rx REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium 600+d calcium plus carbonate/cholecalciferol (vit minerals,calcium- d3)/minerals vitamin d,calcium 600+minerals,cal cium plus,caltrate-600 plus,calcium 600+d & minerals REMOVE FROM FORMULARY Covered Non-Formulary peg 3350/sodium sulfate/sod chloride/kcl/ascorbate sod/vit c BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 563 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 fer-in-sol,ferrous ferrous sulfate sulfate,iron,childr en's ferrous sulfate,children's iron,fer-iron REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 k-pax multivitamin, minerals, calcium, iron, and amino acids REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 k-pax multivitamin, minerals, calcium, iron, and amino acids REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ICAPS MV multivitamin with minerals/folic acid/lutein/zeaxanthin REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calciumcalcium carbonate/vit magnesium-zinc- d3/magnesium ox & vit d stearate/zinc sulf REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 sodium bicarbonate sodium bicarbonate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium plus vitamin d calcium carbonate/vit d3/mag ox/zinc/copper/manganese/ boron REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 fiber therapy,citrucel methylcellulose (with sugar) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 pediatric sodium enema,pedia-lax phosphate,monobasic/sodiu enema m phosphate,dibasic REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 golytely,peg-3350 peg 3350/sod sulf/sod and bicarbonate/sod electrolytes,gavily chloride/potassium chl te-g REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 564 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value calcium carbonate/cholecalciferol (vit d3)/phytonadione REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium soft chew,calcium + vitamin d & k,viactiv 03/31/2016 colyte with flavor peg 3350/sod sulf/sod packets,peg bicarbonate/sod 3350chloride/potassium chl electrolyte,gavilyt e-c REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 GOLYTELY REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 b complex with b- vit 12 b2/niacinamide/pyridoxine hcl/cyanocobalamin/dpanthenol REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 b-complex thiamine hcl/riboflavin/niacinamide/de xpanthenol/pyridoxine REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ferrous sulfate ferrous sulfate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 castor oil castor oil REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium 600-vit calcium d3carbonate/cholecalciferol (vit mineral,calcium d3)/minerals +d & minerals,calcium 600+d & minerals REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium REMOVE FROM FORMULARY Covered Non-Formulary peg 3350/sod sulf/sod bicarbonate/sod chloride/potassium chl calcium carbonate/cholecalciferol (vit d3)/minerals BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 565 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 calcium 600+minerals calcium carbonate/cholecalciferol (vit d3)/minerals REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 HEMATOGEN ferrous fumarate/ascorbic acid/cyanocobalamin/stoma ch conc REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ELDERCAPS multivitamin-minerals no.5/folic acid REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 men's daily multivitamin with multivitminerals/folic acid/lycopene mineral,one daily for men,one daily men's health,men's multivitamin,one daily REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ferrous gluconate ferrous gluconate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 pruvate 217,repliva 21-7,sevate 21-7,ferrex 28 iron asp.glycin & fumarate /vit c/fa/mv comb 11/cathreonate,iron asp.gly,fum/vit c/folic acid/m-vit no.11/calcium threon REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 MYKIDZ IRON 10 ferrous sulfate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 FOSFREE calcium/multivitamin with iron REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 nutr-e-sol,liqui-e vitamin e,tocophersolan REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 corvita 150,corvite 150 iron,carbonyl/folic acid/vit c/pyridoxine hcl/vit b12/zinc REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 566 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 CORVITE FREE multivitamin with min no.6/folic acid/lutein/lycop/ubidecar REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 VITAL-D RX REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 one daily healthy multivit, calcium, weight,one-a-day iron,minerals/folic acid/herb weightsmart complex 145 REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 vitamins for hair REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 daily energy,one multivit,calcium,iron,mineral daily energy s/folic acid/guarana, caffeine REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 PHOS-NAK REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 vitamin bfolic acid/vitamin b complex complex with vit c and c/rice bran REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 vitacon multivitamins with min forte,vicap no.7/folic acid,multivitaminforte,vica-forte,v- minerals no.7/folic acid c forte,therapeutic vitamin wminerals,vic-forte REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium 600 + vit calcium d,calcium carbonate/cholecalciferol creamies (vitamin d3) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 PRO FE REMOVE FROM FORMULARY Covered Non-Formulary vit b complx no.4/cholecalciferol/ascorbic acid/fa/zinc ox mv,iron,min/folic acid/inositol/chol bitart/paba sodium phosphate/potassium phosphates, monobasic and bibasic iron polysaccharide complex BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 567 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value calcium carbonate/magnesium oxide/cholecalciferol (vit d3) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium magnesium + d 03/31/2016 renvela,sevelame sevelamer carbonate r carbonate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 ferosul,ferrous sulfate ferrous sulfate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 vit 3,animi-3,miomega nf omega-3/dha/epa/b12/folic acid/pyridoxine hcl/phytosterols REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 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 03/31/2016 b100 complexvitamin b complex/folic acid folic acid,b-50 complex,complex b-100 REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 FERRETTS ferrous fumarate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 CORAL CALCIUM calcium/magnesium oxide/cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 AQUA-E vitamin e mixed/tocotrienol REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 568 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 centrum multivit with cardio,central-vite calcium,iron,minerals/folic cardio,centrum acid/phytosterol specialist heart,spectravite cardio health,century cardio,century cardio health formula REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 BIO-35 multivit,calcium,iron,min/fa/l utein/lycopene/herbal no.153 REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 BODY, HAIR, multivit,calcium,iron,min/fa/c SKIN AND NAILS hol bit/gelatin/inositol/paba REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 iron,ferraplus 90 iron,carbonyl/folic acid/vitamin b12/vitamin c/docusate na REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 SUPER MULTIPLE multivitamin with minerals/folic acid/dietary suppl no.19 REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 PRO-CAL calcium phosphat/magnesium hydroxide/vit c/vit d3/phosphorus REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 AMITIZA lubiprostone REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 biotin pluscalcium & vit d3 multivitaminmins/calcium/biotin/cholecal ciferol/folic acid REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 coral calcium calcium carbonate REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 calcium gluconate calcium gluconate REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 569 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/31/2016 folbee ar,cardiotek-rx folic acid/arginine hcl/cyanocobalamin/pyridoxi ne/pepper ext REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 vitamin d3,d32000,vitamin d cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 healthy bone formula,calcium 500 calcium carbonate & citrate/mag comb no.12/cholecalciferol,calciu m carbonate,citrate/magnesiu m oxide,aspartate/vit d3 REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 UROMAG,URO- magnesium oxide MAG REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 super bfolic acid/vitamin b comp wcomplex,balance c,folic acid/vitamin b comp d band c complex,super-b complex,bcomplex with vitamin c REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 VITA-RESPA REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 DIALYVITE 5000 multivitamins with minerals no.11/folic acid REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 children's pain acetaminophen and fever,mapap,acet aminophen,nonaspirin,children's nonaspirin,children's acetaminophen,a pra,children's pain relief,st. joseph cyanocobalamin/folic acid/pyridoxine ADD UM: CUSTOM Cumulative 4gm/day Acetaminophen BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 570 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value REMOVE FROM FORMULARY Covered Non-Formulary 03/31/2016 DILAUDID hydromorphone hcl 03/31/2016 methadone hcl methadone hcl 03/31/2016 eryped 200,e.e.s. erythromycin ethylsuccinate 200,erythromycin ethylsuccinate REMOVE UM: AGEQUANTITY 03/31/2016 niacin er CHANGE TIER niacin CHANGE TIER Covered Up to 12 yrs old; 100 / day Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 571 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates April, 2016 Effective Date Brand Name Generic Name Type of Change Previous Value New Value Non-Formulary 04/01/2016 STUART PRENATAL prenatal vitamins with calcium/ferrous fumarate/folic acid REMOVE FROM FORMULARY Covered 04/01/2016 STUART PRENATAL prenatal vitamins with calcium/ferrous fumarate/folic acid REMOVE UM: GENDER Female 04/01/2016 stool docusate sodium softener,soflax,docusate sodium,dulcolax stool softener,doc-qlace,docusoft s,dok,docu soft,colrite,phillips' laxative,womens stool softener,colace,d ss,docusil,correct ol extra gentle,genasoft,u ni-ease,woman's laxative-docusate sod 04/01/2016 sudogest 04/01/2016 copaxone,glatopa glatiramer acetate 04/01/2016 glatopa glatiramer acetate CHANGE TIER 04/06/2016 ACNE MEDICATION benzoyl peroxide REMOVE FROM FORMULARY pseudoephedrine hcl REMOVE UM: QUANTITY REMOVE FROM FORMULARY Covered Non-Formulary REMOVE UM: QUANTITY Covered Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 572 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name benzoyl peroxide Type of Change Previous Value CHANGE TIER New Value 04/06/2016 acne treatment 04/06/2016 acne benzoyl peroxide medication,acne pimple medication 04/06/2016 triple antibiotic neomycin sulfate/bacitracin zinc/polymyxin b CHANGE TIER Covered 04/06/2016 linezolid linezolid CHANGE TIER Covered 04/06/2016 VANDAZOLE metronidazole REMOVE FROM FORMULARY Covered Non-Formulary 04/06/2016 TERAZOL 3 terconazole REMOVE FROM FORMULARY Covered Non-Formulary 04/06/2016 zazole terconazole REMOVE FROM FORMULARY Covered Non-Formulary 04/06/2016 zazole terconazole REMOVE FROM FORMULARY Covered Non-Formulary 04/06/2016 miconazole 3 miconazole nitrate CHANGE TIER 04/06/2016 MONISTAT 3 miconazole nitrate REMOVE FROM FORMULARY 04/06/2016 miconazole 7 miconazole nitrate CHANGE TIER Covered 04/06/2016 miconazole 7 miconazole nitrate CHANGE UM: GENDER Female 04/06/2016 NASAL DECON (PSEUDOEPHE DRINE) pseudoephedrine hcl REMOVE FROM FORMULARY Covered Non-Formulary 04/06/2016 BABY AYR SALINE sodium chloride REMOVE FROM FORMULARY Covered Non-Formulary 04/06/2016 AYR SALINE sodium chloride REMOVE FROM FORMULARY Covered Non-Formulary 04/06/2016 ACCUNEB albuterol sulfate REMOVE FROM FORMULARY Covered Non-Formulary REMOVE FROM FORMULARY Covered Covered Non-Formulary Covered Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 573 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value REMOVE FROM FORMULARY Covered Non-Formulary 04/06/2016 ACCUNEB albuterol sulfate 04/07/2016 theophylline anhydrous theophylline anhydrous CHANGE TIER 04/07/2016 theochron theophylline anhydrous REMOVE FROM FORMULARY Covered Non-Formulary 04/07/2016 theochron theophylline anhydrous REMOVE FROM FORMULARY Covered Non-Formulary 04/07/2016 theophylline theophylline anhydrous CHANGE TIER 04/07/2016 neosporin neomycin sulfate/bacitracin zinc/polymyxin b 04/07/2016 mupirocin mupirocin CHANGE TIER Covered 04/07/2016 ciclopirox ciclopirox ADD TO FORMULARY Covered 04/07/2016 clotrimazole clotrimazole CHANGE TIER Covered 04/07/2016 EFUDEX fluorouracil REMOVE FROM FORMULARY 04/07/2016 diclofenac sodium diclofenac sodium 04/07/2016 malathion,ovide malathion REMOVE UM: AUTHORIZATION 04/07/2016 lice treatment permethrin CHANGE TIER 04/07/2016 SORIATANE acitretin REMOVE FROM FORMULARY 04/07/2016 acitretin acitretin CHANGE TIER Covered 04/07/2016 acitretin acitretin CHANGE UM: AUTHORIZATION PA applies 04/07/2016 acitretin acitretin CHANGE TIER Covered 04/07/2016 acitretin acitretin CHANGE UM: AUTHORIZATION PA applies REMOVE FROM FORMULARY Covered Covered Covered Covered CHANGE TIER Non-Formulary Non-Formulary Covered Covered Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 574 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/07/2016 acitretin acitretin CHANGE TIER Covered 04/07/2016 acitretin acitretin CHANGE UM: AUTHORIZATION PA applies 04/07/2016 THERMAZENE silver sulfadiazine 04/07/2016 silver sulfadiazine silver sulfadiazine CHANGE TIER Covered 04/07/2016 SANTYL collagenase clostridium histolyticum CHANGE TIER Covered 04/07/2016 hydrocortisone hydrocortisone CHANGE TIER Covered 04/07/2016 HYDROSKIN hydrocortisone ADD TO FORMULARY 04/07/2016 hydrocortisone hydrocortisone CHANGE TIER Covered 04/07/2016 triamcinolone acetonide triamcinolone acetonide CHANGE TIER Covered 04/07/2016 triamcinolone acetonide triamcinolone acetonide CHANGE TIER Covered 04/07/2016 CONDYLOX podofilox REMOVE FROM FORMULARY 04/07/2016 lidocaine lidocaine CHANGE TIER Covered 04/07/2016 lidocaine lidocaine CHANGE UM: AUTHORIZATION PA applies 04/07/2016 LIDODERM lidocaine REMOVE FROM FORMULARY Covered 04/07/2016 LIDODERM lidocaine REMOVE UM: AUTHORIZATION PA applies 04/07/2016 NICAZEL niacinamide/azelaic acid/zinc oxide/vit b6/copper/fa REMOVE FROM FORMULARY Covered 04/07/2016 potassium chloride potassium chloride CHANGE TIER REMOVE FROM FORMULARY Covered Non-Formulary Covered Non-Formulary Covered Non-Formulary Non-Formulary Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 575 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/07/2016 potassium chloride potassium chloride CHANGE TIER 04/07/2016 K-TAB ER potassium chloride REMOVE FROM FORMULARY 04/07/2016 potassium chloride potassium chloride CHANGE TIER 04/07/2016 K-TAB ER,K-TAB potassium chloride 04/07/2016 klor-con 10 potassium chloride CHANGE TIER Covered 04/07/2016 potassium chloride potassium chloride CHANGE TIER Covered 04/07/2016 potassium chloride potassium chloride CHANGE TIER Covered 04/07/2016 potassium chloride potassium chloride CHANGE TIER Covered 04/07/2016 klor-con m20 potassium chloride CHANGE TIER Covered 04/07/2016 PRENATABS RX prenatal vits with calcium #76/iron,carbonyl/folic acid 04/07/2016 thrivite rx prenatal vits with calcium #76/iron,carbonyl/folic acid ADD TO FORMULARY Covered 04/07/2016 thrivite rx prenatal vits with calcium #76/iron,carbonyl/folic acid ADD UM: AGE 12 to 55 yrs old 04/07/2016 thrivite rx prenatal vits with calcium #76/iron,carbonyl/folic acid ADD UM: GENDER Female 04/07/2016 prenatal vitamin plus low iron prenatal vits with calcium #72/ferrous fumarate/folic acid CHANGE TIER Covered 04/07/2016 STUART PRENATAL prenatal vitamins with calcium/ferrous fumarate/folic acid REMOVE FROM FORMULARY REMOVE FROM FORMULARY ADD TO FORMULARY Covered Covered Non-Formulary Covered Covered Covered Non-Formulary Non-Formulary Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 576 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value ADD TO FORMULARY Non-Formulary Covered Covered Non-Formulary 04/07/2016 prenatal formula prenatal vitamin with ca no.131/ferrous fumarate/folic acid,prenatal vits with calcium #95/ferrous fumarate/folic acid,prenatal vitamins with calcium/ferrous fumarate/folic acid 04/07/2016 ROCALTROL calcitriol REMOVE FROM FORMULARY 04/07/2016 folic acid folic acid CHANGE TIER Covered 04/07/2016 folic acid folic acid CHANGE TIER Covered 04/07/2016 folic acid folic acid CHANGE TIER Covered 04/07/2016 danazol danazol CHANGE TIER Covered 04/07/2016 ibandronate sodium ibandronate sodium CHANGE TIER Covered 04/07/2016 raloxifene hcl raloxifene hcl CHANGE TIER Covered 04/07/2016 MEDROL methylprednisolone 04/07/2016 prednisone prednisone CHANGE TIER Covered 04/07/2016 prednisone prednisone CHANGE TIER Covered 04/07/2016 prednisone prednisone CHANGE TIER Covered 04/07/2016 prednisone prednisone CHANGE TIER Covered 04/07/2016 prednisone prednisone CHANGE TIER Covered 04/07/2016 PRANDIN repaglinide REMOVE FROM FORMULARY 04/07/2016 repaglinide repaglinide CHANGE TIER Covered 04/07/2016 repaglinide repaglinide CHANGE TIER Covered 04/07/2016 glimepiride glimepiride CHANGE TIER Covered REMOVE FROM FORMULARY Covered Covered Non-Formulary Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 577 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/07/2016 metformin hcl metformin hcl CHANGE TIER 04/07/2016 GLUCOPHAGE metformin hcl REMOVE FROM FORMULARY 04/07/2016 metformin hcl metformin hcl CHANGE TIER Covered 04/07/2016 metformin hcl metformin hcl CHANGE TIER Covered 04/07/2016 metformin hcl er metformin hcl CHANGE TIER Covered 04/07/2016 eemt h.s. estrogens,esterified/methylt estosterone REMOVE FROM FORMULARY Covered Non-Formulary 04/07/2016 eemt estrogens,esterified/methylt estosterone REMOVE FROM FORMULARY Covered Non-Formulary 04/07/2016 jevantique lo norethindrone acetateethinyl estradiol ADD TO FORMULARY Covered 04/07/2016 jevantique lo norethindrone acetateethinyl estradiol ADD UM: GENDER Female 04/07/2016 fyavolv norethindrone acetateethinyl estradiol ADD TO FORMULARY Covered 04/07/2016 fyavolv norethindrone acetateethinyl estradiol ADD TO FORMULARY Covered 04/07/2016 fyavolv norethindrone acetateethinyl estradiol ADD UM: GENDER Female 04/07/2016 CLIMARA estradiol 04/07/2016 desmopressin acetate desmopressin acetate 04/07/2016 WP THYROID thyroid,pork ADD TO FORMULARY Non-Formulary Covered 04/07/2016 WP THYROID thyroid,pork ADD TO FORMULARY Non-Formulary Covered 04/07/2016 WP THYROID thyroid,pork ADD TO FORMULARY Non-Formulary Covered 04/07/2016 WP THYROID thyroid,pork ADD TO FORMULARY Non-Formulary Covered REMOVE FROM FORMULARY Covered Covered Covered CHANGE TIER Non-Formulary Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 578 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value Non-Formulary Covered 04/07/2016 WP THYROID thyroid,pork ADD TO FORMULARY 04/07/2016 WP THYROID thyroid,pork ADD UM: AGE 04/07/2016 WP THYROID thyroid,pork ADD TO FORMULARY 04/07/2016 WP THYROID thyroid,pork ADD UM: AGE 04/07/2016 WP THYROID thyroid,pork ADD TO FORMULARY 04/07/2016 WP THYROID thyroid,pork ADD UM: AGE 0 to 64 yrs old 04/07/2016 ARMOUR THYROID thyroid,pork CHANGE TIER Covered 04/07/2016 WP THYROID thyroid,pork ADD TO FORMULARY 04/07/2016 NATUREthyroid,pork THROID,WESTH ROID ADD UM: AGE 0 to 64 yrs old 04/07/2016 levothyroxine sodium levothyroxine sodium CHANGE TIER Covered 04/07/2016 levothyroxine sodium levothyroxine sodium CHANGE TIER Covered 04/07/2016 levothyroxine sodium levothyroxine sodium CHANGE TIER Covered 04/07/2016 LEVOTHROID levothyroxine sodium ADD TO FORMULARY 04/07/2016 loperamide loperamide hcl 04/07/2016 bismuth bismuth subsalicylate 04/07/2016 diphenoxylateatropine 04/07/2016 0 to 64 yrs old Non-Formulary Covered 0 to 64 yrs old Non-Formulary Non-Formulary Non-Formulary Covered Covered Covered CHANGE TIER Covered ADD TO FORMULARY Covered diphenoxylate hcl/atropine sulfate CHANGE TIER Covered meclizine hcl meclizine hcl CHANGE TIER Covered 04/07/2016 meclizine hcl meclizine hcl CHANGE TIER Covered 04/07/2016 meclizine hcl meclizine hcl CHANGE TIER Covered 04/07/2016 ondansetron hcl ondansetron hcl CHANGE TIER Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 579 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value CHANGE TIER New Value 04/07/2016 ondansetron hcl ondansetron hcl 04/07/2016 ZENPEP lipase/protease/amylase 04/07/2016 ursodiol ursodiol CHANGE TIER Covered 04/07/2016 simethicone simethicone CHANGE TIER Covered 04/07/2016 mytab gas simethicone ADD TO FORMULARY 04/07/2016 simethicone,sime simethicone thicone gas relief CHANGE TIER Covered 04/07/2016 simethicone simethicone CHANGE TIER Covered 04/07/2016 LEVSIN hyoscyamine sulfate REMOVE FROM FORMULARY 04/07/2016 hyoscyamine sulfate hyoscyamine sulfate CHANGE TIER Covered 04/07/2016 hyoscyamine sulfate hyoscyamine sulfate CHANGE TIER Covered 04/07/2016 hyoscyamine sulfate hyoscyamine sulfate CHANGE TIER Covered 04/07/2016 hyoscyamine hyoscyamine sulfate sulfate er,hyoscyamine sulfate,hyoscyam ine sulfate sr CHANGE TIER Covered 04/07/2016 LEVBID hyoscyamine sulfate 04/07/2016 glycopyrrolate glycopyrrolate CHANGE TIER Covered 04/07/2016 dicyclomine hcl dicyclomine hcl CHANGE TIER Covered 04/07/2016 dicyclomine hcl dicyclomine hcl CHANGE TIER Covered 04/07/2016 metoclopramide hcl metoclopramide hcl CHANGE TIER Covered REMOVE FROM FORMULARY REMOVE FROM FORMULARY Covered Covered Non-Formulary Covered Covered Non-Formulary Covered Non-Formulary Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 580 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value REMOVE FROM FORMULARY Covered Non-Formulary 04/07/2016 AZULFIDINE sulfasalazine 04/07/2016 cimetidine cimetidine CHANGE TIER Covered 04/07/2016 ranitidine hcl,ranitidine ranitidine hcl CHANGE TIER Covered 04/07/2016 acid reducer ranitidine hcl CHANGE TIER Covered 04/07/2016 ranitidine hcl ranitidine hcl CHANGE TIER Covered 04/07/2016 acid reducer,acid ranitidine hcl reducer 150 CHANGE TIER Covered 04/07/2016 ranitidine hcl ranitidine hcl CHANGE TIER Covered 04/07/2016 acid reducer famotidine CHANGE TIER Covered 04/07/2016 famotidine famotidine CHANGE TIER Covered 04/07/2016 famotidine famotidine CHANGE TIER Covered 04/07/2016 lansoprazole lansoprazole CHANGE TIER Covered 04/07/2016 lansoprazole lansoprazole CHANGE TIER Covered 04/07/2016 omeprazole omeprazole CHANGE TIER Covered 04/07/2016 misoprostol misoprostol CHANGE TIER Covered 04/07/2016 sucralfate sucralfate CHANGE TIER Covered 04/07/2016 tamsulosin hcl tamsulosin hcl CHANGE TIER Covered 04/07/2016 finasteride finasteride CHANGE TIER Covered 04/07/2016 phenazopyridine phenazopyridine hcl hcl CHANGE TIER Covered 04/07/2016 phenazopyridine phenazopyridine hcl hcl CHANGE TIER Covered 04/07/2016 oxybutynin chloride CHANGE TIER Covered oxybutynin chloride BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 581 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/07/2016 oxybutynin chloride er oxybutynin chloride CHANGE TIER Covered 04/07/2016 oxybutynin chloride er oxybutynin chloride CHANGE TIER Covered 04/07/2016 oxybutynin chloride er oxybutynin chloride CHANGE TIER Covered 04/07/2016 sodium citrate & citric acid citric acid/sodium citrate CHANGE TIER Covered 04/07/2016 potassium citrate- potassium citrate/citric acid citric acid CHANGE TIER Covered 04/07/2016 bethanechol chloride bethanechol chloride CHANGE TIER Covered 04/07/2016 warfarin sodium warfarin sodium CHANGE TIER Covered 04/07/2016 warfarin sodium warfarin sodium CHANGE TIER Covered 04/07/2016 pentoxifylline pentoxifylline CHANGE TIER Covered 04/07/2016 cilostazol cilostazol CHANGE TIER Covered 04/07/2016 PLETAL cilostazol REMOVE FROM FORMULARY Covered Non-Formulary 04/07/2016 AGRYLIN anagrelide hcl REMOVE FROM FORMULARY Covered Non-Formulary 04/07/2016 aspirin,children's aspirin aspirin CHANGE TIER Covered 04/07/2016 aspirin ec aspirin CHANGE TIER Covered 04/07/2016 cyclosporine cyclosporine CHANGE TIER Covered 04/07/2016 tacrolimus tacrolimus CHANGE TIER Covered 04/07/2016 tacrolimus tacrolimus CHANGE TIER Covered 04/07/2016 tacrolimus tacrolimus CHANGE TIER Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 582 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value Covered Non-Formulary 04/07/2016 RAPAMUNE sirolimus REMOVE FROM FORMULARY 04/07/2016 sirolimus sirolimus CHANGE TIER Covered 04/07/2016 cyclobenzaprine hcl cyclobenzaprine hcl CHANGE TIER Covered 04/07/2016 methocarbamol methocarbamol CHANGE TIER Covered 04/07/2016 tizanidine hcl tizanidine hcl CHANGE TIER Covered 04/07/2016 tizanidine hcl tizanidine hcl CHANGE TIER Covered 04/07/2016 prevident sodium fluoride 04/07/2016 natural balance tears dextran 70/hypromellose ADD TO FORMULARY Covered 04/07/2016 nature's tears dextran 70/hypromellose ADD TO FORMULARY Covered 04/07/2016 neosporin neomycin sulfate/polymyxin b sulfate/gramicidin d 04/07/2016 gentamicin sulfate gentamicin sulfate 04/07/2016 CILOXAN ciprofloxacin hcl 04/07/2016 erythromycin erythromycin base 04/07/2016 VIROPTIC trifluridine REMOVE FROM FORMULARY Covered Non-Formulary 04/07/2016 trifluridine trifluridine ADD TO FORMULARY Non-Formulary Covered 04/07/2016 allergy eye naphazoline hcl/pheniramine maleate 04/07/2016 mydfrin phenylephrine hcl REMOVE FROM FORMULARY Covered Non-Formulary 04/07/2016 ISOPTO CARPINE pilocarpine hcl REMOVE FROM FORMULARY Covered Non-Formulary REMOVE FROM FORMULARY REMOVE FROM FORMULARY Covered Covered CHANGE TIER REMOVE FROM FORMULARY Non-Formulary Non-Formulary Covered Covered CHANGE TIER Non-Formulary Covered CHANGE TIER Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 583 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/07/2016 TIMOPTIC-XE timolol maleate REMOVE FROM FORMULARY Covered Non-Formulary 04/07/2016 IOPIDINE apraclonidine hcl REMOVE FROM FORMULARY Covered Non-Formulary 04/07/2016 ISOPTO ATROPINE atropine sulfate REMOVE FROM FORMULARY Covered Non-Formulary 04/07/2016 acetasol hc acetic acid/hydrocortisone REMOVE FROM FORMULARY Covered Non-Formulary 04/07/2016 neomycinneomycin sulfate/polymyxin polymyxinb sulfate/hydrocortisone hydrocort,neomy cin-polymyxin-hc CHANGE TIER Covered 04/07/2016 chlorpheniramine chlorpheniramine maleate maleate CHANGE TIER Covered 04/07/2016 diphenhydramine diphenhydramine hcl hcl CHANGE TIER Covered 04/07/2016 allergy relief diphenhydramine hcl CHANGE TIER Covered 04/07/2016 diphenhydramine diphenhydramine hcl hcl CHANGE TIER Covered 04/07/2016 diphenhydramine diphenhydramine hcl hcl CHANGE TIER Covered 04/07/2016 promethazine hcl promethazine hcl CHANGE TIER Covered 04/07/2016 cyproheptadine hcl CHANGE TIER Covered 04/07/2016 children's diphenhydramine hcl allergy,children's allergy relief CHANGE TIER Covered 04/07/2016 cetirizine hcl cetirizine hcl CHANGE TIER Covered 04/07/2016 children's allergy cetirizine hcl relief CHANGE TIER Covered cyproheptadine hcl BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 584 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value ADD TO FORMULARY Non-Formulary Covered 04/07/2016 CHILDREN'S ZYRTEC cetirizine hcl 04/07/2016 loratadine loratadine CHANGE TIER Covered 04/07/2016 allergy relief,allergy loratadine CHANGE TIER Covered 04/07/2016 CHILDREN'S CLARITIN loratadine ADD TO FORMULARY Non-Formulary Covered 04/07/2016 PULMICORT budesonide REMOVE FROM FORMULARY Covered Non-Formulary 04/07/2016 AEROSPAN flunisolide 04/11/2016 CHANGE TIER Covered non-aspirin extra acetaminophen strength ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 non-aspirin extra acetaminophen strength ADD UM: QUANTITY 4 / Day 04/11/2016 mapap acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 mapap acetaminophen ADD UM: QUANTITY 4 / Day 04/11/2016 tylophen acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 tylophen acetaminophen ADD UM: QUANTITY 4 / Day 04/11/2016 pain reliever acetaminophen ADD UM: QUANTITY 4 / Day 04/11/2016 pain reliever acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 pain relief acetaminophen ADD UM: QUANTITY 4 / Day 04/11/2016 pain relief acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 acetaminophen acetaminophen ADD TO FORMULARY Covered 04/11/2016 acetaminophen acetaminophen ADD UM: QUANTITY 8 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 585 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 8 / Day 8 / Day 04/11/2016 acetaminophen acetaminophen CHANGE UM: QUANTITY 04/11/2016 acetaminophen acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 tactinal acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 tactinal acetaminophen CHANGE UM: QUANTITY 8 / Day 8 / Day 04/11/2016 pain reliever acetaminophen CHANGE UM: QUANTITY 8 / Day 8 / Day 04/11/2016 pain reliever acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 pain reliever acetaminophen ADD TO FORMULARY Covered 04/11/2016 non-aspirin pain relief acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 non-aspirin pain relief acetaminophen CHANGE UM: QUANTITY 04/11/2016 mapap acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 MAPAP acetaminophen ADD UM: QUANTITY 8 / Day 04/11/2016 mapap acetaminophen CHANGE UM: QUANTITY 04/11/2016 MAPAP acetaminophen ADD TO FORMULARY Covered 04/11/2016 pain relief acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 pain relief acetaminophen CHANGE UM: QUANTITY 04/11/2016 TYLENOL acetaminophen ADD UM: CUSTOM 04/11/2016 TYLENOL acetaminophen CHANGE UM: QUANTITY 8 / Day 8 / Day 04/11/2016 TYLENOL acetaminophen ADD TO FORMULARY Non-Formulary Covered 04/11/2016 non-aspirin acetaminophen ADD UM: CUSTOM 8 / Day 8 / Day 8 / Day 8 / Day 8 / Day 8 / Day Max of 4000MG of Apap/day Max of 4000MG of Apap/day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 586 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 non-aspirin acetaminophen CHANGE UM: QUANTITY 8 / Day 8 / Day 04/11/2016 medi-tabs acetaminophen CHANGE UM: QUANTITY 8 / Day 8 / Day 04/11/2016 medi-tabs acetaminophen ADD UM: CUSTOM 04/11/2016 athenol acetaminophen CHANGE UM: QUANTITY 04/11/2016 athenol acetaminophen ADD UM: CUSTOM 04/11/2016 masophen acetaminophen CHANGE UM: QUANTITY 04/11/2016 masophen acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 pharbetol acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 pharbetol acetaminophen CHANGE UM: QUANTITY 04/11/2016 q-pap acetaminophen ADD UM: CUSTOM 04/11/2016 q-pap acetaminophen CHANGE UM: QUANTITY 8 / Day 8 / Day 04/11/2016 PAIN & FEVER acetaminophen CHANGE UM: QUANTITY 8 / Day 8 / Day 04/11/2016 PAIN & FEVER acetaminophen ADD UM: CUSTOM 04/11/2016 mapap acetaminophen CHANGE UM: CUSTOM Cumulative: 4gm/day acetaminophen Max of 4000MG of Apap/day 04/11/2016 mapap acetaminophen CHANGE UM: QUANTITY 4 / Day 4 / Day 04/11/2016 pain reliever acetaminophen ADD UM: CUSTOM 04/11/2016 pain reliever acetaminophen CHANGE UM: CUSTOM 04/11/2016 pain reliever acetaminophen ADD TO FORMULARY Max of 4000MG of Apap/day 8 / Day 8 / Day Max of 4000MG of Apap/day 8 / Day 8 / Day 8 / Day 8 / Day Max of 4000MG of Apap/day Max of 4000MG of Apap/day Max of 4000MG of Apap/day Cumulative: 4gm/day acetaminophen Max of 4000MG of Apap/day Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 587 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 pain reliever acetaminophen ADD UM: QUANTITY 4 / Day 04/11/2016 pain reliever acetaminophen CHANGE UM: QUANTITY 4 / Day 4 / Day 04/11/2016 acetaminophen acetaminophen extra strength,acetami nophen CHANGE UM: CUSTOM Cumulative: 4gm/day acetaminophen Max of 4000MG of Apap/day 04/11/2016 acetaminophen acetaminophen extra strength,acetami nophen CHANGE UM: QUANTITY 4 / Day 4 / Day 04/11/2016 masophen acetaminophen CHANGE UM: CUSTOM Cumulative: 4gm/day acetaminophen Max of 4000MG of Apap/day 04/11/2016 masophen acetaminophen CHANGE UM: QUANTITY 4 / Day 4 / Day 04/11/2016 medi-tabs extra strength acetaminophen CHANGE UM: QUANTITY 4 / Day 4 / Day 04/11/2016 medi-tabs extra strength acetaminophen CHANGE UM: CUSTOM Cumulative: 4gm/day acetaminophen Max of 4000MG of Apap/day 04/11/2016 non-aspirin pain relief acetaminophen CHANGE UM: QUANTITY 4 / Day 4 / Day 04/11/2016 non-aspirin pain relief,pain relief acetaminophen CHANGE UM: CUSTOM Cumulative: 4gm/day acetaminophen Max of 4000MG of Apap/day 04/11/2016 tactinal acetaminophen CHANGE UM: CUSTOM Cumulative: 4gm/day acetaminophen Max of 4000MG of Apap/day 04/11/2016 tactinal acetaminophen CHANGE UM: QUANTITY 4 / Day 4 / Day 04/11/2016 acetaminophen acetaminophen ADD TO FORMULARY Covered 04/11/2016 acetaminophen acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 588 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value CHANGE UM: CUSTOM Cumulative: 4gm/day acetaminophen Max of 4000MG of Apap/day 04/11/2016 acetaminophen,a acetaminophen cetaminophen es,pain reliever 04/11/2016 acetaminophen 04/11/2016 acetaminophen,a acetaminophen cetaminophen es,pain reliever CHANGE UM: QUANTITY 4 / Day 4 / Day 04/11/2016 extra strength non-aspirin,nonaspirin extra strength acetaminophen CHANGE UM: QUANTITY 4 / Day 4 / Day 04/11/2016 extra strength non-aspirin,nonaspirin extra strength acetaminophen CHANGE UM: CUSTOM Cumulative: 4gm/day acetaminophen Max of 4000MG of Apap/day 04/11/2016 TYLENOL EXTRA STRENGTH acetaminophen ADD TO FORMULARY 04/11/2016 TYLENOL EXTRA STRENGTH acetaminophen ADD TO FORMULARY Non-Formulary Covered 04/11/2016 TYLENOL EXTRA STRENGTH acetaminophen CHANGE UM: QUANTITY 4 / Day 4 / Day 04/11/2016 TYLENOL EXTRA STRENGTH acetaminophen CHANGE UM: CUSTOM Cumulative: 4gm/day acetaminophen Max of 4000MG of Apap/day 04/11/2016 medi-tabs acetaminophen CHANGE UM: CUSTOM Cumulative: 4gm/day acetaminophen Max of 4000MG of Apap/day 04/11/2016 medi-tabs acetaminophen CHANGE UM: QUANTITY 4 / Day 4 / Day acetaminophen ADD UM: QUANTITY 4 / Day Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 589 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 pain reliever acetaminophen CHANGE UM: CUSTOM Cumulative: 4gm/day acetaminophen Max of 4000MG of Apap/day 04/11/2016 pain reliever acetaminophen CHANGE UM: QUANTITY 4 / Day 4 / Day 04/11/2016 pain acetaminophen relief,acetaminop hen CHANGE UM: QUANTITY 4 / Day 4 / Day 04/11/2016 pain acetaminophen relief,acetaminop hen CHANGE UM: CUSTOM Cumulative: 4gm/day acetaminophen Max of 4000MG of Apap/day 04/11/2016 pain relief 04/11/2016 pain relief,pain acetaminophen relief extra strength,acetami nophen 04/11/2016 pain relief 04/11/2016 pain relief,pain acetaminophen relief extra strength,acetami nophen 04/11/2016 pain relief acetaminophen ADD TO FORMULARY 04/11/2016 pharbetol acetaminophen CHANGE UM: QUANTITY 4 / Day 4 / Day 04/11/2016 pharbetol acetaminophen CHANGE UM: CUSTOM Cumulative: 4gm/day acetaminophen Max of 4000MG of Apap/day 04/11/2016 q-pap extra strength acetaminophen CHANGE UM: CUSTOM Cumulative: 4gm/day acetaminophen Max of 4000MG of Apap/day 04/11/2016 q-pap extra strength acetaminophen CHANGE UM: QUANTITY 4 / Day 4 / Day acetaminophen acetaminophen ADD UM: QUANTITY CHANGE UM: QUANTITY 4 / Day 4 / Day ADD UM: CUSTOM CHANGE UM: CUSTOM 4 / Day Max of 4000MG of Apap/day Cumulative: 4gm/day acetaminophen Max of 4000MG of Apap/day Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 590 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value CHANGE UM: CUSTOM Cumulative: 4gm/day acetaminophen Max of 4000MG of Apap/day 04/11/2016 acetaminophen,a acetaminophen cetaminophen pain relief 04/11/2016 acetaminophen acetaminophen CHANGE UM: QUANTITY 4 / Day 4 / Day 04/11/2016 pain & fever acetaminophen CHANGE UM: QUANTITY 4 / Day 4 / Day 04/11/2016 pain & fever acetaminophen CHANGE UM: CUSTOM Cumulative: 4gm/day acetaminophen Max of 4000MG of Apap/day 04/11/2016 shake that ache acetaminophen CHANGE UM: CUSTOM Cumulative: 4gm/day acetaminophen Max of 4000MG of Apap/day 04/11/2016 shake that ache acetaminophen CHANGE UM: QUANTITY 4 / Day 4 / Day 04/11/2016 children's tactinal acetaminophen CHANGE UM: CUSTOM Cumulative: 4gm/day acetaminophen Max of 4000MG of Apap/day 04/11/2016 children's tactinal acetaminophen CHANGE UM: QUANTITY 50 / Day 50 / Day 04/11/2016 mapap acetaminophen CHANGE UM: QUANTITY 50 / Day 50 / Day 04/11/2016 mapap acetaminophen CHANGE UM: CUSTOM Cumulative: 4gm/day acetaminophen Max of 4000MG of Apap/day 04/11/2016 children's nonaspirin acetaminophen CHANGE UM: QUANTITY 50 / Day 50 / Day 04/11/2016 children's nonaspirin acetaminophen CHANGE UM: CUSTOM Cumulative: 4gm/day acetaminophen Max of 4000MG of Apap/day 04/11/2016 acetaminophen acetaminophen ADD TO FORMULARY 04/11/2016 acetaminophen,c acetaminophen hildren's acetaminophen CHANGE UM: QUANTITY Covered 50 / Day 50 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 591 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 acetaminophen,c acetaminophen hildren's acetaminophen CHANGE UM: CUSTOM Cumulative: 4gm/day acetaminophen Max of 4000MG of Apap/day 04/11/2016 children's nonaspirin,nonaspirin acetaminophen CHANGE UM: CUSTOM Cumulative: 4gm/day acetaminophen Max of 4000MG of Apap/day 04/11/2016 children's nonaspirin,nonaspirin acetaminophen CHANGE UM: QUANTITY 50 / Day 50 / Day 04/11/2016 children's pain & acetaminophen fever CHANGE UM: QUANTITY 50 / Day 50 / Day 04/11/2016 children's pain & acetaminophen fever CHANGE UM: CUSTOM Cumulative: 4gm/day acetaminophen Max of 4000MG of Apap/day 04/11/2016 children's nonaspirin acetaminophen CHANGE UM: QUANTITY 50 / Day 50 / Day 04/11/2016 children's nonaspirin acetaminophen CHANGE UM: CUSTOM Cumulative: 4gm/day acetaminophen Max of 4000MG of Apap/day 04/11/2016 non-aspirin acetaminophen CHANGE UM: QUANTITY 50 / Day 50 / Day 04/11/2016 non-aspirin acetaminophen CHANGE UM: CUSTOM Cumulative: 4gm/day acetaminophen Max of 4000MG of Apap/day 04/11/2016 children's pain reliever acetaminophen CHANGE UM: CUSTOM Cumulative: 4gm/day acetaminophen Max of 4000MG of Apap/day 04/11/2016 children's pain reliever acetaminophen CHANGE UM: QUANTITY 50 / Day 50 / Day 04/11/2016 childrens acetaminophen acetaminophen,c hildren's acetaminophen CHANGE UM: CUSTOM Cumulative: 4gm/day acetaminophen Max of 4000MG of Apap/day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 592 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value CHANGE UM: QUANTITY 50 / Day 50 / Day 04/11/2016 childrens acetaminophen acetaminophen,c hildren's acetaminophen 04/11/2016 acetaminophen acetaminophen ADD UM: CUSTOM 04/11/2016 acetaminophen acetaminophen CHANGE UM: QUANTITY 04/11/2016 ed-apap acetaminophen ADD UM: CUSTOM 04/11/2016 ed-apap acetaminophen CHANGE UM: QUANTITY 04/11/2016 children's silapap acetaminophen ADD UM: CUSTOM 04/11/2016 children's silapap acetaminophen CHANGE UM: QUANTITY 04/11/2016 children's acetaminophen acetaminophen,p ain relief ADD UM: CUSTOM 04/11/2016 children's acetaminophen acetaminophen,p ain relief CHANGE UM: QUANTITY 04/11/2016 q-pap,children's q-pap acetaminophen ADD UM: CUSTOM 04/11/2016 q-pap,children's q-pap acetaminophen CHANGE UM: QUANTITY 20 / Day 20 / Day 04/11/2016 children's nonaspirin acetaminophen CHANGE UM: QUANTITY 20 / Day 20 / Day 04/11/2016 children's nonaspirin acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 MAPAP acetaminophen ADD UM: QUANTITY 20 / Day 04/11/2016 mapap acetaminophen CHANGE UM: QUANTITY Max of 4000MG of Apap/day 20 / Day 20 / Day Max of 4000MG of Apap/day 20 / Day 20 / Day Max of 4000MG of Apap/day 20 / Day 20 / Day Max of 4000MG of Apap/day 20 / Day 20 / Day Max of 4000MG of Apap/day 20 / Day 20 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 593 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 mapap acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 MAPAP acetaminophen ADD TO FORMULARY Covered 04/11/2016 children's pain relief acetaminophen CHANGE UM: QUANTITY 04/11/2016 children's pain relief acetaminophen ADD UM: CUSTOM 04/11/2016 acetaminophen acetaminophen CHANGE UM: QUANTITY 04/11/2016 acetaminophen acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 infant's nonaspirin,infants' non-aspirin acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 infant's nonaspirin,infants' non-aspirin acetaminophen CHANGE UM: QUANTITY 04/11/2016 infant's pain relief acetaminophen ADD UM: CUSTOM 04/11/2016 infant's pain relief acetaminophen CHANGE UM: QUANTITY 04/11/2016 infants' pain reliever,infant's pain reliever acetaminophen ADD UM: CUSTOM 04/11/2016 infants' pain reliever,infant's pain reliever acetaminophen CHANGE UM: QUANTITY 04/11/2016 mapap infant acetaminophen ADD UM: CUSTOM 04/11/2016 mapap infant acetaminophen CHANGE UM: QUANTITY 04/11/2016 acetaminophen acetaminophen ADD UM: CUSTOM 20 / Day 20 / Day Max of 4000MG of Apap/day 40 / Day 40 / Day 40 / Day 40 / Day Max of 4000MG of Apap/day 40 / Day 40 / Day Max of 4000MG of Apap/day 40 / Day 40 / Day Max of 4000MG of Apap/day 40 / Day 40 / Day Max of 4000MG of Apap/day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 594 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 20 / Day 125 / Day 04/11/2016 acetaminophen acetaminophen CHANGE UM: QUANTITY 04/11/2016 children's meditabs acetaminophen ADD UM: CUSTOM 04/11/2016 children's meditabs acetaminophen CHANGE UM: QUANTITY 04/11/2016 children's q-pap acetaminophen ADD UM: CUSTOM 04/11/2016 children's q-pap acetaminophen CHANGE UM: QUANTITY 20 / Day 125 / Day 04/11/2016 CHILDREN'S TYLENOL acetaminophen CHANGE UM: QUANTITY 20 / Day 125 / Day 04/11/2016 CHILDREN'S TYLENOL acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 non-aspirin acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 non-aspirin acetaminophen CHANGE UM: QUANTITY 04/11/2016 children's pain reliever acetaminophen ADD UM: CUSTOM 04/11/2016 children's pain reliever acetaminophen CHANGE UM: QUANTITY 04/11/2016 children's pain relief acetaminophen ADD UM: CUSTOM 04/11/2016 children's pain relief acetaminophen CHANGE UM: QUANTITY 20 / Day 125 / Day 04/11/2016 mapap acetaminophen CHANGE UM: QUANTITY 20 / Day 125 / Day 04/11/2016 mapap acetaminophen ADD UM: CUSTOM 04/11/2016 children's nonaspirin acetaminophen CHANGE UM: QUANTITY Max of 4000MG of Apap/day 20 / Day 125 / Day Max of 4000MG of Apap/day 20 / Day 125 / Day Max of 4000MG of Apap/day 20 / Day 125 / Day Max of 4000MG of Apap/day Max of 4000MG of Apap/day 20 / Day 125 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 595 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 children's nonaspirin acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 nortemp acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 nortemp acetaminophen CHANGE UM: QUANTITY 04/11/2016 betatemp acetaminophen ADD UM: CUSTOM 04/11/2016 betatemp acetaminophen CHANGE UM: QUANTITY 04/11/2016 children's acetaminophen acetaminophen,c hildrens suspension 04/11/2016 children's acetaminophen acetaminophen CHANGE UM: QUANTITY 04/11/2016 pediacare fever reducer acetaminophen ADD UM: CUSTOM 04/11/2016 pediacare fever reducer acetaminophen CHANGE UM: QUANTITY 20 / Day 125 / Day 04/11/2016 infant pain acetaminophen relief,infant painfever CHANGE UM: QUANTITY 20 / Day 125 / Day 04/11/2016 infant pain acetaminophen relief,infant painfever ADD UM: CUSTOM 04/11/2016 infants' pain acetaminophen relief,infant's pain relief CHANGE UM: QUANTITY 04/11/2016 infants' pain acetaminophen relief,infant's pain relief ADD UM: CUSTOM 20 / Day 125 / Day Max of 4000MG of Apap/day 20 / Day ADD UM: CUSTOM 125 / Day Max of 4000MG of Apap/day 20 / Day 125 / Day Max of 4000MG of Apap/day Max of 4000MG of Apap/day 20 / Day 125 / Day Max of 4000MG of Apap/day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 596 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 20 / Day 125 / Day 04/11/2016 infant painacetaminophen fever,infants' pain-fever,infants' pain relief,infants' pain reliever CHANGE UM: QUANTITY 04/11/2016 infant painacetaminophen fever,infants' pain-fever,infants' pain relief,infants' pain reliever ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 children's painfever acetaminophen ADD UM: QUANTITY 125 / Day 04/11/2016 children's painfever acetaminophen CHANGE UM: QUANTITY 04/11/2016 children's painfever acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 children's painfever acetaminophen ADD TO FORMULARY Covered 04/11/2016 INFANTS' TYLENOL acetaminophen ADD TO FORMULARY Covered 04/11/2016 INFANTS' TYLENOL acetaminophen CHANGE UM: QUANTITY 04/11/2016 INFANTS' TYLENOL acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 fever reducerpain reliever,infant fever-pain reliever acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day 20 / Day 20 / Day 125 / Day 125 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 597 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name acetaminophen Type of Change Previous Value New Value CHANGE UM: QUANTITY 20 / Day 125 / Day 04/11/2016 fever reducerpain reliever,infant fever-pain reliever 04/11/2016 infants' painacetaminophen fever,infant painfever ADD UM: CUSTOM 04/11/2016 infants' painacetaminophen fever,infant painfever CHANGE UM: QUANTITY 20 / Day 125 / Day 04/11/2016 little remedies fever-pain acetaminophen CHANGE UM: QUANTITY 20 / Day 125 / Day 04/11/2016 little remedies fever-pain acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 children's acetaminophen acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 children's acetaminophen acetaminophen ADD UM: QUANTITY 30 / Day 04/11/2016 children's nonaspirin acetaminophen ADD UM: QUANTITY 40 / Day 04/11/2016 children's nonaspirin acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 infants pain reliever,infant's pain relief acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 infants pain reliever acetaminophen ADD UM: QUANTITY 40 / Day 04/11/2016 acetaminophen acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 acetaminophen acetaminophen ADD UM: QUANTITY 40 / Day Max of 4000MG of Apap/day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 598 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 infant's nonaspirin acetaminophen ADD UM: QUANTITY 40 / Day 04/11/2016 infant's nonaspirin acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 medi-tabs pain reliever acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 medi-tabs pain reliever acetaminophen ADD UM: QUANTITY 40 / Day 04/11/2016 infant's pain reliever acetaminophen ADD UM: QUANTITY 40 / Day 04/11/2016 infant's pain reliever acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 q-pap acetaminophen ADD UM: QUANTITY 40 / Day 04/11/2016 q-pap acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 nortemp acetaminophen ADD UM: QUANTITY 40 / Day 04/11/2016 nortemp acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 SILAPAP acetaminophen ADD TO FORMULARY 04/11/2016 SILAPAP acetaminophen ADD UM: QUANTITY 40 / Day 04/11/2016 SILAPAP acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 infant's acetaminophen acetaminophen ADD UM: QUANTITY 40 / Day 04/11/2016 infant's acetaminophen acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 non-aspirin acetaminophen CHANGE UM: CUSTOM Non-Formulary Cumulative 4gm/day Acetaminophen Covered Max of 4000MG of Apap/day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 599 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 non-aspirin acetaminophen ADD UM: QUANTITY 30 / Day 04/11/2016 mapap acetaminophen ADD UM: QUANTITY 30 / Day 04/11/2016 mapap acetaminophen CHANGE UM: CUSTOM 04/11/2016 acetaminophen acetaminophen ADD UM: QUANTITY 04/11/2016 acetaminophen acetaminophen CHANGE UM: CUSTOM Cumulative 4gm/day Acetaminophen Max of 4000MG of Apap/day 04/11/2016 children's acetaminophen acetaminophen CHANGE UM: CUSTOM Cumulative 4gm/day Acetaminophen Max of 4000MG of Apap/day 04/11/2016 children's acetaminophen acetaminophen ADD UM: QUANTITY 04/11/2016 children's nonaspirin acetaminophen CHANGE UM: CUSTOM 04/11/2016 children's nonaspirin acetaminophen ADD UM: QUANTITY 04/11/2016 children's pain and fever acetaminophen CHANGE UM: CUSTOM 04/11/2016 children's pain and fever acetaminophen ADD UM: QUANTITY 30 / Day 04/11/2016 acetaminophen acetaminophen ADD UM: QUANTITY 30 / Day 04/11/2016 acetaminophen acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 acetaminophen acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 acetaminophen acetaminophen ADD UM: QUANTITY 124.923 / Day Cumulative 4gm/day Acetaminophen Max of 4000MG of Apap/day 30 / Day 30 / Day Cumulative 4gm/day Acetaminophen Max of 4000MG of Apap/day 30 / Day Cumulative 4gm/day Acetaminophen Max of 4000MG of Apap/day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 600 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 acetaminophen acetaminophen ADD UM: QUANTITY 124.923 / Day 04/11/2016 acetaminophen acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 acetaminophen acetaminophen CHANGE UM: QUANTITY 04/11/2016 acetaminophen acetaminophen CHANGE UM: CUSTOM 04/11/2016 ACEPHEN acetaminophen CHANGE UM: QUANTITY 04/11/2016 ACEPHEN acetaminophen CHANGE UM: CUSTOM 04/11/2016 feverall acetaminophen CHANGE UM: QUANTITY 04/11/2016 feverall acetaminophen CHANGE UM: CUSTOM Cumulative: MED Max of 4000MG 200mg/day of Apap/day 04/11/2016 children's nonaspirin acetaminophen CHANGE UM: CUSTOM Cumulative: MED Max of 4000MG 200mg/day of Apap/day 04/11/2016 children's nonaspirin acetaminophen CHANGE UM: QUANTITY 04/11/2016 children's fever acetaminophen reducer,children's fever reducing 04/11/2016 children's fever reducing acetaminophen CHANGE UM: QUANTITY 4 / Day 4 / Day 04/11/2016 fever acetaminophen reducer,children's fever reducer CHANGE UM: QUANTITY 4 / Day 4 / Day 04/11/2016 fever acetaminophen reducer,children's fever reducer CHANGE UM: CUSTOM 04/11/2016 child pain relfever reducer acetaminophen CHANGE UM: CUSTOM CHANGE UM: QUANTITY 4 / Day 4 / Day Cumulative: MED Max of 4000MG 200mg/day of Apap/day 4 / Day 4 / Day Cumulative: MED Max of 4000MG 200mg/day of Apap/day 4 / Day 4 / Day 4 / Day 4 / Day Cumulative: MED Max of 4000MG 200mg/day of Apap/day Cumulative: MED Max of 4000MG 200mg/day of Apap/day 4 / Day 4 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 601 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 child pain relfever reducer acetaminophen CHANGE UM: CUSTOM Cumulative: MED Max of 4000MG 200mg/day of Apap/day 04/11/2016 feverall acetaminophen CHANGE UM: QUANTITY 04/11/2016 feverall acetaminophen CHANGE UM: CUSTOM Cumulative: MED Max of 4000MG 200mg/day of Apap/day 04/11/2016 acephen acetaminophen CHANGE UM: CUSTOM Cumulative: MED Max of 4000MG 200mg/day of Apap/day 04/11/2016 acephen acetaminophen CHANGE UM: QUANTITY 04/11/2016 acetaminophen acetaminophen ADD UM: CUSTOM 04/11/2016 acetaminophen acetaminophen CHANGE UM: QUANTITY 6 / Day 6 / Day 04/11/2016 feverall acetaminophen CHANGE UM: QUANTITY 6 / Day 6 / Day 04/11/2016 feverall acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 acephen acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 acephen acetaminophen CHANGE UM: QUANTITY 6 / Day 6 / Day 04/11/2016 butalbitalbutalbital/acetaminophen acetaminophen,a cetaminophenbutalbital CHANGE UM: CUSTOM Cumulative: 4Mg/Day Acetaminophen. Max of 4000MG of Apap/day 04/11/2016 butalbitalacetaminophen butalbital/acetaminophen ADD TO FORMULARY 04/11/2016 butalbitalacetaminophen butalbital/acetaminophen CHANGE UM: QUANTITY 4 / Day 4 / Day 04/11/2016 tencon butalbital/acetaminophen CHANGE UM: CUSTOM Cumulative: 4gm/day acetaminophen Max of 4000MG of Apap/day 04/11/2016 tencon butalbital/acetaminophen CHANGE UM: QUANTITY 4 / Day 4 / Day 4 / Day 4 / Day 4 / Day 4 / Day Max of 4000MG of Apap/day Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 602 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value CHANGE UM: CUSTOM Cumulative: 4gm/day acetaminophen Max of 4000MG of Apap/day 04/11/2016 butalbitalacetaminophencaffe butalbital/acetaminophen/caf feine 04/11/2016 butalbitalacetaminophencaffe butalbital/acetaminophen/caf CHANGE UM: QUANTITY feine 4 / Day 4 / Day 04/11/2016 capacet butalbital/acetaminophen/caf CHANGE UM: QUANTITY feine 4 / Day 4 / Day 04/11/2016 capacet butalbital/acetaminophen/caf feine CHANGE UM: CUSTOM Cumulative: 4gm/day acetaminophen Max of 4000MG of Apap/day 04/11/2016 butalbitalacetaminophencaffe butalbital/acetaminophen/caf feine ADD TO FORMULARY Covered 04/11/2016 butalbitalacetaminophencaffe butalbital/acetaminophen/caf feine ADD UM: AGE 10 to 64 yrs old 04/11/2016 butalbitalacetaminophencaffe butalbital/acetaminophen/caf feine ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 butalbitalacetaminophencaffe butalbital/acetaminophen/caf feine CHANGE UM: CUSTOM 04/11/2016 butalbitalacetaminophencaffe butalbital/acetaminophen/caf feine ADD UM: QUANTITY 04/11/2016 butalbitalacetaminophencaffe butalbital/acetaminophen/caf CHANGE UM: QUANTITY feine 04/11/2016 ENBREL etanercept 04/11/2016 ENBREL 04/11/2016 ENBREL Cumulative: 4gm/day acetaminophen Max of 4000MG of Apap/day 4 / Day 4 / Day 4 / Day CHANGE UM: QUANTITY 0.27 / day 0.27 / Day etanercept CHANGE UM: QUANTITY 0.14 / day 0.14 / Day etanercept CHANGE UM: QUANTITY 0.16 / day 0.16 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 603 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 ENBREL etanercept CHANGE UM: QUANTITY 0.14 / day 0.14 / Day 04/11/2016 HUMIRA PEN adalimumab CHANGE UM: QUANTITY 0.15 / day 0.15 / Day 04/11/2016 HUMIRA PEN CROHN-UC-HS STARTER adalimumab CHANGE UM: QUANTITY 0.15 / day 0.15 / Day 04/11/2016 HUMIRA PEN PSORIASISUVEITIS adalimumab CHANGE UM: QUANTITY 0.15 / day 0.15 / Day 04/11/2016 HUMIRA adalimumab ADD UM: AUTHORIZATION 04/11/2016 HUMIRA adalimumab CHANGE UM: QUANTITY 0.08 / day 0.08 / Day 04/11/2016 HUMIRA adalimumab CHANGE UM: QUANTITY 0.08 / day 0.08 / Day 04/11/2016 HUMIRA adalimumab ADD UM: AUTHORIZATION 04/11/2016 HUMIRA adalimumab CHANGE UM: QUANTITY 04/11/2016 HUMIRA adalimumab ADD UM: AUTHORIZATION 04/11/2016 HUMIRA PEDIATRIC CROHN'S adalimumab CHANGE UM: QUANTITY 04/11/2016 HUMIRA PEDIATRIC CROHN'S adalimumab ADD UM: AUTHORIZATION 04/11/2016 leflunomide leflunomide CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 leflunomide leflunomide CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 celecoxib celecoxib ADD UM: AUTHORIZATION PA applies 04/11/2016 celecoxib celecoxib ADD TO FORMULARY Covered 04/11/2016 celecoxib celecoxib ADD UM: QUANTITY 1 / Day 04/11/2016 celecoxib celecoxib CHANGE UM: QUANTITY 04/11/2016 celecoxib celecoxib ADD UM: AUTHORIZATION PA applies 04/11/2016 celecoxib celecoxib ADD TO FORMULARY Covered PA applies PA applies 0.15 / day 0.15 / Day PA applies 0.15 / day 0.15 / Day PA applies 1 / Day 1 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 604 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 celecoxib celecoxib ADD UM: QUANTITY 1 / Day 04/11/2016 celecoxib celecoxib CHANGE UM: QUANTITY 04/11/2016 celecoxib celecoxib ADD TO FORMULARY Covered 04/11/2016 celecoxib celecoxib ADD UM: QUANTITY 1 / Day 04/11/2016 celecoxib celecoxib CHANGE UM: QUANTITY 04/11/2016 celecoxib celecoxib ADD UM: AUTHORIZATION PA applies 04/11/2016 celecoxib celecoxib ADD UM: QUANTITY 1 / Day 04/11/2016 celecoxib celecoxib CHANGE UM: QUANTITY 04/11/2016 celecoxib celecoxib ADD TO FORMULARY Covered 04/11/2016 celecoxib celecoxib ADD UM: AUTHORIZATION PA applies 04/11/2016 ketorolac tromethamine ketorolac tromethamine ADD TO FORMULARY Covered 04/11/2016 ketorolac tromethamine ketorolac tromethamine ADD UM: AGE Up to 64 yrs old 04/11/2016 nabumetone nabumetone ADD UM: QUANTITY 2 / Day 04/11/2016 nabumetone nabumetone CHANGE UM: QUANTITY 04/11/2016 nabumetone nabumetone ADD TO FORMULARY Covered 04/11/2016 nabumetone nabumetone ADD UM: QUANTITY 2 / Day 04/11/2016 nabumetone nabumetone CHANGE UM: QUANTITY 04/11/2016 nabumetone nabumetone ADD TO FORMULARY Covered 04/11/2016 meloxicam meloxicam ADD TO FORMULARY Covered 04/11/2016 meloxicam meloxicam ADD UM: QUANTITY 1 / Day 04/11/2016 meloxicam meloxicam CHANGE UM: QUANTITY 04/11/2016 meloxicam meloxicam ADD TO FORMULARY Covered 04/11/2016 meloxicam meloxicam ADD UM: QUANTITY 1 / Day 1 / Day 1 / Day 1 / Day 2 / Day 2 / Day 1 / Day 1 / Day 1 / Day 1 / Day 2 / Day 2 / Day 1 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 605 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 meloxicam meloxicam 04/11/2016 diclofenac sodium diclofenac sodium ADD TO FORMULARY Covered 04/11/2016 diclofenac sodium diclofenac sodium ADD TO FORMULARY Covered 04/11/2016 diclofenac sodium diclofenac sodium ADD TO FORMULARY Covered 04/11/2016 diclofenac sodium er diclofenac sodium ADD TO FORMULARY Covered 04/11/2016 ibuprofen ibuprofen CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 ADVIL LIQUIGELS,ADVIL ibuprofen CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 ADVIL,ADVIL LIQUI-GELS ibuprofen ADD TO FORMULARY Non-Formulary Covered 04/11/2016 ADVIL MIGRAINE ibuprofen ADD TO FORMULARY Non-Formulary Covered 04/11/2016 ADVIL MIGRAINE ibuprofen CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 wal-profen ibuprofen CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 ibuprofen ibuprofen ADD TO FORMULARY Covered 04/11/2016 ibuprofen ib ibuprofen ADD TO FORMULARY Covered 04/11/2016 ibuprofen ibuprofen ADD TO FORMULARY Covered 04/11/2016 ibuprofen ibuprofen ADD TO FORMULARY Covered 04/11/2016 ibuprofen ibuprofen ADD TO FORMULARY Covered 04/11/2016 infants ibuprofen ibuprofen,ibuprof en,infants' ibuprofen CHANGE UM: QUANTITY 3 / Day 3 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 606 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 children's ibuprofen ibuprofen CHANGE UM: QUANTITY 3 / Day 3 / Day 04/11/2016 infant's ibuprofen ibuprofen,infants ibuprofen,infants' ibuprofen CHANGE UM: QUANTITY 3 / Day 3 / Day 04/11/2016 infants mediprofen ibuprofen CHANGE UM: QUANTITY 3 / Day 3 / Day 04/11/2016 infants ibu-drops ibuprofen CHANGE UM: QUANTITY 3 / Day 3 / Day 04/11/2016 INFANT'S ibuprofen MOTRIN,INFANT S' MOTRIN CHANGE UM: QUANTITY 3 / Day 3 / Day 04/11/2016 INFANT'S ibuprofen MOTRIN,INFANT S' MOTRIN ADD TO FORMULARY Non-Formulary Covered 04/11/2016 infants profenib ibuprofen CHANGE UM: QUANTITY 3 / Day 3 / Day 04/11/2016 ibu-drops ibuprofen CHANGE UM: QUANTITY 3 / Day 3 / Day 04/11/2016 children's mediprofen ibuprofen CHANGE UM: QUANTITY 1 / Day 3 / Day 04/11/2016 ibuprofen ibuprofen CHANGE UM: QUANTITY 1 / Day 3 / Day 04/11/2016 children's advil ibuprofen CHANGE UM: QUANTITY 1 / Day 3 / Day 04/11/2016 CHILDREN'S ibuprofen MOTRIN,MOTRI N ADD TO FORMULARY Non-Formulary Covered 04/11/2016 CHILDREN'S MOTRIN ibuprofen CHANGE UM: QUANTITY 1 / Day 3 / Day 04/11/2016 children's ibuprofen ibuprofen ADD UM: QUANTITY 04/11/2016 children's ibuprofen ibuprofen CHANGE UM: QUANTITY 3 / Day 1 / Day 3 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 607 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name ibuprofen Type of Change Previous Value ADD TO FORMULARY New Value 04/11/2016 children's ibuprofen 04/11/2016 children's ibuprofen profenib,children' s profen ib 04/11/2016 naproxen naproxen ADD TO FORMULARY Covered 04/11/2016 naproxen naproxen ADD TO FORMULARY Covered 04/11/2016 naproxen naproxen ADD TO FORMULARY Covered 04/11/2016 naproxen naproxen ADD TO FORMULARY Covered 04/11/2016 naproxen naproxen ADD TO FORMULARY Covered 04/11/2016 naproxen naproxen ADD TO FORMULARY Covered 04/11/2016 all day pain relief naproxen sodium CHANGE UM: QUANTITY 180 / 30 Days 3 / Day 04/11/2016 mediproxen naproxen sodium CHANGE UM: QUANTITY 180 / 30 Days 3 / Day 04/11/2016 naproxen sodium naproxen sodium CHANGE UM: QUANTITY 180 / 30 Days 3 / Day 04/11/2016 all day relief,naproxen sodium,all day pain relief naproxen sodium CHANGE UM: QUANTITY 180 / 30 Days 3 / Day 04/11/2016 wal-proxen naproxen sodium CHANGE UM: QUANTITY 180 / 30 Days 3 / Day 04/11/2016 flanax naproxen sodium CHANGE UM: QUANTITY 180 / 30 Days 3 / Day 04/11/2016 indomethacin indomethacin ADD UM: AGE Up to 64 yrs old 04/11/2016 indomethacin indomethacin ADD TO FORMULARY Covered 04/11/2016 indomethacin indomethacin CHANGE UM: AGE 04/11/2016 indomethacin indomethacin ADD TO FORMULARY Covered 04/11/2016 butalbital-aspirin- butalbital/aspirin/caffeine caffeine ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 butalbital-aspirin- butalbital/aspirin/caffeine caffeine CHANGE UM: AGE CHANGE UM: QUANTITY Covered 1 / Day 0 to 64 yrs old 0 to 64 yrs old 3 / Day Up to 64 yrs old Up to 64 yrs old BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 608 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value CHANGE UM: QUANTITY 4 / Day 4 / Day 04/11/2016 butalbital-aspirin- butalbital/aspirin/caffeine caffeine 04/11/2016 aspirin aspirin ADD UM: AGE 40 to 79 yrs old 04/11/2016 aspirin aspirin ADD TO FORMULARY Covered 04/11/2016 aspirin aspirin ADD UM: QUANTITY 1 / Day 04/11/2016 aspirin aspirin CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 lite coat aspirin aspirin CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 ecpirin aspirin CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 aspir-trin aspirin CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 bufferin aspirin/calcium carbonate/magnesium CHANGE UM: AGE 40 to 79 yrs old At least 40 yrs old 04/11/2016 codeine sulfate codeine sulfate CHANGE UM: QUANTITY 3 / Day 3 / Day 04/11/2016 codeine sulfate codeine sulfate CHANGE UM: QUANTITY 3 / Day 3 / Day 04/11/2016 codeine sulfate codeine sulfate CHANGE UM: QUANTITY 3 / Day 3 / Day 04/11/2016 fentanyl fentanyl ADD TO FORMULARY Covered 04/11/2016 fentanyl fentanyl ADD UM: AUTHORIZATION PA applies 04/11/2016 fentanyl fentanyl ADD UM: CUSTOM 200Mg/Day Cumulative Edit 04/11/2016 fentanyl fentanyl CHANGE UM: QUANTITY 04/11/2016 fentanyl fentanyl ADD UM: CUSTOM 04/11/2016 fentanyl fentanyl CHANGE UM: QUANTITY 0.333 / day 0.3333 / Day 04/11/2016 fentanyl fentanyl CHANGE UM: QUANTITY 0.333 / day 0.3333 / Day 04/11/2016 fentanyl fentanyl ADD UM: CUSTOM 04/11/2016 fentanyl fentanyl CHANGE UM: QUANTITY 0.333 / day 0.3333 / Day 200Mg/Day Cumulative Edit 200Mg/Day Cumulative Edit 0.333 / day 0.3333 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 609 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 fentanyl fentanyl ADD UM: CUSTOM 200Mg/Day Cumulative Edit 04/11/2016 fentanyl fentanyl CHANGE UM: QUANTITY 04/11/2016 fentanyl fentanyl ADD UM: CUSTOM 04/11/2016 hydromorphone hcl hydromorphone hcl CHANGE UM: CUSTOM 04/11/2016 hydromorphone hcl hydromorphone hcl CHANGE UM: QUANTITY 04/11/2016 hydromorphone hcl hydromorphone hcl CHANGE UM: CUSTOM 04/11/2016 hydromorphone hcl hydromorphone hcl CHANGE UM: QUANTITY 04/11/2016 hydromorphone hcl hydromorphone hcl ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 hydromorphone hcl hydromorphone hcl ADD UM: QUANTITY 32 / Day 04/11/2016 hydromorphone hcl hydromorphone hcl ADD UM: CUSTOM 200Mg/Day Cumulative Edit 04/11/2016 hydromorphone hcl hydromorphone hcl ADD UM: QUANTITY 4 / Day 04/11/2016 meperidine hcl meperidine hcl ADD UM: CUSTOM 200Mg/Day Cumulative Edit 04/11/2016 meperidine hcl meperidine hcl CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 meperidine hcl meperidine hcl CHANGE UM: AGE 0 to 64 yrs old Up to 64 yrs old 04/11/2016 meperidine hcl meperidine hcl CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 meperidine hcl meperidine hcl ADD UM: CUSTOM 200Mg/Day Cumulative Edit 04/11/2016 meperidine hcl meperidine hcl ADD UM: AGE Up to 64 yrs old 0.333 / day 0.3333 / Day 200Mg/Day Cumulative Edit Cumulative: MED 200Mg/Day 200mg/day Cumulative Edit 4 / Day 4 / Day Cumulative: MED 200Mg/Day 200mg/day Cumulative Edit 4 / Day 4 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 610 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 0 to 64 yrs old Up to 64 yrs old 04/11/2016 meperidine hcl meperidine hcl CHANGE UM: AGE 04/11/2016 meperidine hcl meperidine hcl ADD UM: CUSTOM 04/11/2016 meperidine hcl meperidine hcl CHANGE UM: QUANTITY 10 / day 10 / Day 04/11/2016 methadone hcl methadone hcl CHANGE UM: QUANTITY 4 / Day 4 / Day 04/11/2016 methadone hcl methadone hcl ADD TO FORMULARY Covered 04/11/2016 methadone hcl methadone hcl ADD UM: CUSTOM 200Mg/Day Cumulative Edit 04/11/2016 methadone hcl methadone hcl ADD UM: CUSTOM 200Mg/Day Cumulative Edit 04/11/2016 methadone hcl methadone hcl ADD UM: QUANTITY 4 / Day 04/11/2016 methadone hcl methadone hcl CHANGE UM: QUANTITY 04/11/2016 methadone hcl methadone hcl ADD TO FORMULARY 04/11/2016 METHADOSE methadone hcl CHANGE UM: CUSTOM 04/11/2016 METHADOSE methadone hcl CHANGE UM: QUANTITY 8 / Day 8 / Day 04/11/2016 METHADOSE methadone hcl ADD TO FORMULARY Non-Formulary Covered 04/11/2016 methadone intensol methadone hcl CHANGE UM: QUANTITY 8 / Day 8 / Day 04/11/2016 methadone intensol methadone hcl CHANGE UM: CUSTOM 04/11/2016 methadone hcl methadone hcl ADD UM: CUSTOM 04/11/2016 methadone hcl methadone hcl CHANGE UM: QUANTITY 04/11/2016 methadone hcl methadone hcl CHANGE UM: CUSTOM 04/11/2016 methadone hcl methadone hcl CHANGE UM: QUANTITY 200Mg/Day Cumulative Edit 4 / Day 4 / Day Covered Cumulative: MED 200Mg/Day 200mg/day Cumulative Edit Cumulative: MED 200Mg/Day 200mg/day Cumulative Edit 200Mg/Day Cumulative Edit 30 / Day 30 / Day Cumulative: MED 200Mg/Day 200mg/day Cumulative Edit 20 / Day 20 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 611 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 methadone hcl methadone hcl ADD UM: CUSTOM 200Mg/Day Cumulative Edit 04/11/2016 methadone hcl methadone hcl ADD UM: QUANTITY 3 / Day 04/11/2016 morphine sulfate morphine sulfate CHANGE UM: QUANTITY 04/11/2016 morphine sulfate morphine sulfate ADD UM: CUSTOM 04/11/2016 morphine sulfate morphine sulfate CHANGE UM: CUSTOM 04/11/2016 morphine sulfate morphine sulfate CHANGE UM: QUANTITY 04/11/2016 morphine sulfate morphine sulfate er ADD UM: QUANTITY 04/11/2016 morphine sulfate morphine sulfate er CHANGE UM: QUANTITY 04/11/2016 morphine sulfate morphine sulfate er ADD TO FORMULARY Covered 04/11/2016 morphine sulfate morphine sulfate er ADD UM: CUSTOM 200Mg/Day Cumulative Edit 04/11/2016 morphine morphine sulfate sulfate,morphine sulfate er,morphine sulfate cr CHANGE UM: CUSTOM 04/11/2016 morphine sulfate morphine sulfate er,morphine sulfate,morphine sulfate cr ADD UM: CUSTOM 200Mg/Day Cumulative Edit 04/11/2016 morphine sulfate morphine sulfate er ADD UM: QUANTITY 2 / Day 04/11/2016 morphine sulfate morphine sulfate er CHANGE UM: QUANTITY 4 / Day 4 / Day 200Mg/Day Cumulative Edit Cumulative: MED 200Mg/Day 200mg/day Cumulative Edit 4 / Day 4 / Day 2 / Day 2 / Day 2 / Day Cumulative: MED 200Mg/Day 200mg/day Cumulative Edit 2 / Day 2 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 612 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 morphine sulfate morphine sulfate er ADD TO FORMULARY Covered 04/11/2016 morphine sulfate morphine sulfate er ADD UM: QUANTITY 2 / Day 04/11/2016 morphine sulfate morphine sulfate er CHANGE UM: QUANTITY 04/11/2016 morphine sulfate morphine sulfate er ADD UM: CUSTOM 04/11/2016 morphine sulfate morphine sulfate er,morphine sulfate,morphine sulfate cr CHANGE UM: CUSTOM 04/11/2016 morphine sulfate morphine sulfate er ADD TO FORMULARY Covered 04/11/2016 morphine sulfate morphine sulfate er ADD UM: CUSTOM 200Mg/Day Cumulative Edit 04/11/2016 morphine sulfate morphine sulfate er,morphine sulfate,morphine sulfate cr CHANGE UM: CUSTOM 04/11/2016 morphine sulfate morphine sulfate er ADD UM: QUANTITY 04/11/2016 morphine sulfate morphine sulfate er CHANGE UM: QUANTITY 04/11/2016 morphine sulfate morphine sulfate er ADD TO FORMULARY Covered 04/11/2016 morphine sulfate morphine sulfate ADD UM: QUANTITY 8 / Day 04/11/2016 morphine sulfate morphine sulfate CHANGE UM: QUANTITY 04/11/2016 morphine sulfate morphine sulfate ADD UM: CUSTOM 200Mg/Day Cumulative Edit 04/11/2016 morphine sulfate morphine sulfate ADD TO FORMULARY Covered 2 / Day 2 / Day 200Mg/Day Cumulative Edit Cumulative: MED 200Mg/Day 200mg/day Cumulative Edit Cumulative: MED 200Mg/Day 200mg/day Cumulative Edit 2 / Day 2 / Day 8 / Day 2 / Day 8 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 613 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 morphine sulfate morphine sulfate ADD UM: CUSTOM 200Mg/Day Cumulative Edit 04/11/2016 morphine sulfate morphine sulfate CHANGE UM: QUANTITY 8 / Day 8 / Day 04/11/2016 morphine sulfate morphine sulfate CHANGE UM: QUANTITY 8 / Day 8 / Day 04/11/2016 morphine sulfate morphine sulfate ADD UM: CUSTOM 200Mg/Day Cumulative Edit 04/11/2016 oxycodone hcl oxycodone hcl ADD UM: QUANTITY 4 / Day 04/11/2016 oxycodone hcl oxycodone hcl CHANGE UM: QUANTITY 04/11/2016 oxycodone hcl oxycodone hcl ADD TO FORMULARY Covered 04/11/2016 oxycodone hcl oxycodone hcl ADD UM: CUSTOM 200Mg/Day Cumulative Edit 04/11/2016 tramadol hcl tramadol hcl ADD UM: QUANTITY 4 / Day 04/11/2016 tramadol hcl tramadol hcl CHANGE UM: QUANTITY 04/11/2016 tramadol hcl tramadol hcl ADD TO FORMULARY Covered 04/11/2016 acetaminophencodeine acetaminophen with codeine phosphate ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 acetaminophencodeine acetaminophen with codeine CHANGE UM: QUANTITY phosphate 04/11/2016 acetaminophencodeine acetaminophen with codeine phosphate 04/11/2016 acetaminophencodeine acetaminophen with codeine CHANGE UM: QUANTITY phosphate 04/11/2016 acetaminophencodeine acetaminophen with codeine phosphate ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 acetaminophencodeine acetaminophen with codeine phosphate ADD TO FORMULARY Covered 04/11/2016 acetaminophencodeine acetaminophen with codeine CHANGE UM: QUANTITY phosphate 4 / Day 4 / Day 6 / Day ADD UM: QUANTITY 4 / Day 4 / Day 6 / Day 6 / Day 6 / Day 6 / Day 6 / Day 6 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 614 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 acetaminophencodeine acetaminophen with codeine phosphate ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 acetaminophencodeine acetaminophen with codeine phosphate ADD UM: QUANTITY 90 / Day 04/11/2016 acetaminophencodeine acetaminophen with codeine phosphate ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 acetaminophencodeine acetaminophen with codeine phosphate ADD UM: QUANTITY 90 / Day 04/11/2016 acetaminophencodeine acetaminophen with codeine phosphate ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 acetaminophencodeine acetaminophen with codeine phosphate ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 acetaminophencodeine acetaminophen with codeine CHANGE UM: QUANTITY phosphate 04/11/2016 butalb-caffacetaminophcodein butalbital/acetaminophen/caf feine/codeine phosphate 04/11/2016 butalb-caffacetaminophcodein butalbital/acetaminophen/caf CHANGE UM: QUANTITY feine/codeine phosphate 04/11/2016 asa-butalbcodeine caffeine-codeine phosphate/butalbital/aspirin/ caffeine ADD TO FORMULARY Covered 04/11/2016 asa-butalbcodeine caffeine-codeine phosphate/butalbital/aspirin/ caffeine ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 asa-butalbcodeine caffeine-codeine phosphate/butalbital/aspirin/ caffeine CHANGE UM: QUANTITY 4 / Day 4 / Day 04/11/2016 butalbital compoundcodeine CHANGE UM: QUANTITY 4 / Day 4 / Day codeine phosphate/butalbital/aspirin/ caffeine 2 / Day ADD UM: CUSTOM 2 / Day Max of 4000MG of Apap/day 4 / Day 4 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 615 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 butalbital compoundcodeine codeine phosphate/butalbital/aspirin/ caffeine ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 ascomp with codeine codeine phosphate/butalbital/aspirin/ caffeine ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 ascomp with codeine codeine phosphate/butalbital/aspirin/ caffeine CHANGE UM: QUANTITY 04/11/2016 hydrocodoneacetaminophen hydrocodone bitartrate/acetaminophen,hy drocodone bit/acetaminophen ADD UM: CUSTOM 200Mg/Day Cumulative Edit 04/11/2016 hydrocodoneacetaminophen hydrocodone bitartrate/acetaminophen ADD UM: QUANTITY 4 / Day 04/11/2016 hydrocodoneacetaminophen hydrocodone bitartrate/acetaminophen CHANGE UM: QUANTITY 04/11/2016 hydrocodoneacetaminophen hydrocodone bitartrate/acetaminophen ADD TO FORMULARY 04/11/2016 lortab hydrocodone bitartrate/acetaminophen CHANGE UM: QUANTITY 04/11/2016 lortab hydrocodone bitartrate/acetaminophen ADD UM: CUSTOM 04/11/2016 lorcet hd hydrocodone bitartrate/acetaminophen CHANGE UM: QUANTITY 04/11/2016 lorcet hd hydrocodone bitartrate/acetaminophen ADD UM: CUSTOM 200Mg/Day Cumulative Edit 04/11/2016 hydrocodoneacetaminophen hydrocodone bitartrate/acetaminophen ADD TO FORMULARY Covered 4 / Day 4 / Day 4 / Day 4 / Day Covered 4 / Day 4 / Day 200Mg/Day Cumulative Edit 4 / Day 4 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 616 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value ADD UM: CUSTOM 200Mg/Day Cumulative Edit 4 / Day 04/11/2016 hydrocodoneacetaminophen hydrocodone bitartrate/acetaminophen,hy drocodone bit/acetaminophen 04/11/2016 hydrocodoneacetaminophen hydrocodone bitartrate/acetaminophen ADD UM: QUANTITY 04/11/2016 hydrocodoneacetaminophen hydrocodone bitartrate/acetaminophen CHANGE UM: QUANTITY 4 / Day 4 / Day 04/11/2016 lorcet hydrocodone bitartrate/acetaminophen CHANGE UM: QUANTITY 4 / Day 4 / Day 04/11/2016 lorcet hydrocodone bitartrate/acetaminophen ADD UM: CUSTOM 200Mg/Day Cumulative Edit 04/11/2016 lortab hydrocodone bitartrate/acetaminophen ADD UM: CUSTOM 200Mg/Day Cumulative Edit 04/11/2016 lortab hydrocodone bitartrate/acetaminophen CHANGE UM: QUANTITY 04/11/2016 hydrocodoneacetaminophen hydrocodone bitartrate/acetaminophen ADD TO FORMULARY 04/11/2016 hydrocodoneacetaminophen hydrocodone bitartrate/acetaminophen CHANGE UM: QUANTITY 04/11/2016 hydrocodoneacetaminophen hydrocodone bitartrate/acetaminophen,hy drocodone bit/acetaminophen ADD UM: CUSTOM 200Mg/Day Cumulative Edit 04/11/2016 lortab hydrocodone bitartrate/acetaminophen ADD UM: CUSTOM 200Mg/Day Cumulative Edit 04/11/2016 lortab hydrocodone bitartrate/acetaminophen CHANGE UM: QUANTITY 04/11/2016 lorcet plus hydrocodone bitartrate/acetaminophen ADD UM: CUSTOM 4 / Day 4 / Day Covered 4 / Day 4 / Day 4 / Day 4 / Day 200Mg/Day Cumulative Edit BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 617 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 lorcet plus hydrocodone bitartrate/acetaminophen CHANGE UM: QUANTITY 4 / Day 4 / Day 04/11/2016 hydrocodoneacetaminophen hydrocodone bitartrate/acetaminophen CHANGE UM: QUANTITY 1800 / 30 Days 60 / Day 04/11/2016 hydrocodoneacetaminophen hydrocodone bitartrate/acetaminophen CHANGE UM: CUSTOM Max of 4000MG of Apap/day Max of 4000MG of Apap/day + 200Mg/Day Cumulative Edit 04/11/2016 hydrocodoneacetaminophen hydrocodone bitartrate/acetaminophen CHANGE UM: QUANTITY 0.111 / day 120 / Day 04/11/2016 hydrocodoneacetaminophen hydrocodone bitartrate/acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day 04/11/2016 oxycodoneacetaminophen oxycodone hcl/acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day + 200Mg/Day Cumulative Edit 04/11/2016 oxycodoneacetaminophen oxycodone hcl/acetaminophen ADD UM: QUANTITY 4 / Day 04/11/2016 oxycodoneacetaminophen oxycodone hcl/acetaminophen CHANGE UM: QUANTITY 04/11/2016 oxycodoneacetaminophen oxycodone hcl/acetaminophen ADD TO FORMULARY 04/11/2016 endocet oxycodone hcl/acetaminophen CHANGE UM: QUANTITY 04/11/2016 endocet oxycodone hcl/acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day + 200Mg/Day Cumulative Edit 04/11/2016 roxicet oxycodone hcl/acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day + 200Mg/Day Cumulative Edit 4 / Day 4 / Day Covered 4 / Day 4 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 618 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 4 / Day 4 / Day 04/11/2016 roxicet oxycodone hcl/acetaminophen CHANGE UM: QUANTITY 04/11/2016 oxycodoneacetaminophen oxycodone hcl/acetaminophen ADD TO FORMULARY Covered 04/11/2016 oxycodoneacetaminophen oxycodone hcl/acetaminophen ADD UM: QUANTITY 4 / Day 04/11/2016 oxycodoneacetaminophen oxycodone hcl/acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day + 200Mg/Day Cumulative Edit 04/11/2016 endocet oxycodone hcl/acetaminophen ADD UM: QUANTITY 4 / Day 04/11/2016 endocet oxycodone hcl/acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day + 200Mg/Day Cumulative Edit 04/11/2016 oxycodoneoxycodone acetaminophen,o hcl/acetaminophen xycodone hclacetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day + 200Mg/Day Cumulative Edit 04/11/2016 oxycodoneacetaminophen oxycodone hcl/acetaminophen ADD TO FORMULARY Covered 04/11/2016 oxycodoneacetaminophen oxycodone hcl/acetaminophen ADD UM: QUANTITY 4 / Day 04/11/2016 oxycodoneacetaminophen oxycodone hcl/acetaminophen CHANGE UM: QUANTITY 4 / Day 4 / Day 04/11/2016 endocet oxycodone hcl/acetaminophen CHANGE UM: QUANTITY 4 / Day 4 / Day 04/11/2016 endocet oxycodone hcl/acetaminophen ADD UM: CUSTOM Max of 4000MG of Apap/day + 200Mg/Day Cumulative Edit BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 619 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name 04/11/2016 pentazocinenaloxone hcl pentazocine hcl/naloxone hcl 04/11/2016 neomycin sulfate neomycin sulfate 04/11/2016 tobramycin 04/11/2016 Type of Change Previous Value New Value ADD UM: QUANTITY 12 / Day ADD TO FORMULARY Covered tobramycin in 0.225 % sodium chloride ADD UM: AUTHORIZATION PA applies tobramycin tobramycin in 0.225 % sodium chloride ADD TO FORMULARY Covered 04/11/2016 amoxicillin amoxicillin ADD TO FORMULARY Covered 04/11/2016 amoxicillin amoxicillin ADD TO FORMULARY Covered 04/11/2016 amoxicillin amoxicillin ADD TO FORMULARY Covered 04/11/2016 amoxicillin amoxicillin CHANGE UM: AGE 0 to 12 yrs old Up to 12 yrs old 04/11/2016 amoxicillin amoxicillin CHANGE UM: AGE 0 to 12 yrs old Up to 12 yrs old 04/11/2016 amoxicillin amoxicillin ADD UM: AGE Up to 12 yrs old 04/11/2016 amoxicillin amoxicillin ADD TO FORMULARY Covered 04/11/2016 amoxicillinclavulanate potass amoxicillin/potassium clavulanate ADD TO FORMULARY Covered 04/11/2016 amoxicillinclavulanate potass amoxicillin/potassium clavulanate ADD TO FORMULARY Covered 04/11/2016 amoxicillinclavulanate potass amoxicillin/potassium clavulanate ADD TO FORMULARY Covered 04/11/2016 amoxicillinclavulanate potass amoxicillin/potassium clavulanate CHANGE UM: AGE 04/11/2016 sulfamethoxazole sulfamethoxazole/trimethopr -trimethoprim im Up to 3 yrs old ADD TO FORMULARY Up to 12 yrs old Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 620 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 sulfamethoxazole sulfamethoxazole/trimethopr -trimethoprim im ADD TO FORMULARY Covered 04/11/2016 dapsone dapsone ADD TO FORMULARY Covered 04/11/2016 dapsone dapsone ADD TO FORMULARY Covered 04/11/2016 isoniazid isoniazid ADD TO FORMULARY Covered 04/11/2016 cefadroxil cefadroxil ADD TO FORMULARY Covered 04/11/2016 cephalexin cephalexin ADD TO FORMULARY Covered 04/11/2016 cephalexin cephalexin ADD TO FORMULARY Covered 04/11/2016 cefaclor cefaclor CHANGE UM: AGE 0 to 12 yrs old Up to 12 yrs old 04/11/2016 cefaclor cefaclor CHANGE UM: AGE 0 to 12 yrs old Up to 12 yrs old 04/11/2016 cefaclor cefaclor ADD UM: AGE 04/11/2016 cefaclor cefaclor CHANGE UM: AGE 04/11/2016 cefaclor cefaclor ADD TO FORMULARY Covered 04/11/2016 cefprozil cefprozil ADD TO FORMULARY Covered 04/11/2016 cefpodoxime proxetil cefpodoxime proxetil CHANGE UM: AGE 0 to 12 yrs old Up to 12 yrs old 04/11/2016 cefpodoxime proxetil cefpodoxime proxetil CHANGE UM: AGE 0 to 12 yrs old Up to 12 yrs old 04/11/2016 ciprofloxacin ciprofloxacin CHANGE UM: AGE 0 to 12 yrs old Up to 12 yrs old 04/11/2016 ciprofloxacin ciprofloxacin CHANGE UM: AGE 0 to 12 yrs old Up to 12 yrs old 04/11/2016 levofloxacin levofloxacin ADD TO FORMULARY Covered 04/11/2016 levofloxacin levofloxacin ADD TO FORMULARY Covered 04/11/2016 vancomycin hcl vancomycin hcl ADD TO FORMULARY Covered 04/11/2016 vancomycin hcl vancomycin hcl ADD TO FORMULARY Covered 04/11/2016 clindamycin hcl clindamycin hcl ADD TO FORMULARY Covered 04/11/2016 clindamycin hcl clindamycin hcl ADD TO FORMULARY Covered Up to 12 yrs old 0 to 12 yrs old Up to 12 yrs old BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 621 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 clindamycin pediatric clindamycin palmitate hcl ADD TO FORMULARY Covered 04/11/2016 clindamycin pediatric clindamycin palmitate hcl ADD UM: AGE Up to 12 yrs old 04/11/2016 erythromycin erythromycin base ADD TO FORMULARY Covered 04/11/2016 E.E.S. 200 erythromycin ethylsuccinate ADD UM: AGE Up to 12 yrs old 04/11/2016 E.E.S. 200 erythromycin ethylsuccinate ADD UM: QUANTITY 6.7 / Day 04/11/2016 azithromycin azithromycin ADD TO FORMULARY Covered 04/11/2016 azithromycin azithromycin ADD TO FORMULARY Covered 04/11/2016 clarithromycin clarithromycin ADD TO FORMULARY Covered 04/11/2016 clarithromycin clarithromycin ADD TO FORMULARY Covered 04/11/2016 clarithromycin clarithromycin CHANGE UM: AGE 0 to 12 yrs old Up to 12 yrs old 04/11/2016 clarithromycin clarithromycin CHANGE UM: AGE 0 to 12 yrs old Up to 12 yrs old 04/11/2016 penicillin v potassium penicillin v potassium CHANGE UM: AGE 0 to 12 yrs old Up to 12 yrs old 04/11/2016 penicillin v potassium penicillin v potassium CHANGE UM: AGE 0 to 12 yrs old Up to 12 yrs old 04/11/2016 doxycycline monohydrate doxycycline monohydrate ADD TO FORMULARY Covered 04/11/2016 doxycycline monohydrate doxycycline monohydrate ADD TO FORMULARY Covered 04/11/2016 doxycycline monohydrate doxycycline monohydrate ADD TO FORMULARY Covered 04/11/2016 doxycycline doxycycline monohydrate monohydrate,dox ycycline 04/11/2016 minocycline hcl minocycline hcl ADD TO FORMULARY Covered 04/11/2016 minocycline hcl minocycline hcl ADD TO FORMULARY Covered CHANGE UM: AGE 0 to 12 yrs old Up to 12 yrs old BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 622 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 1 / Day 1 / Day 04/11/2016 terbinafine hcl terbinafine hcl CHANGE UM: QUANTITY 04/11/2016 terbinafine hcl terbinafine hcl ADD TO FORMULARY Covered 04/11/2016 ketoconazole ketoconazole ADD UM: QUANTITY 2 / Day 04/11/2016 ketoconazole ketoconazole CHANGE UM: QUANTITY 04/11/2016 ketoconazole ketoconazole ADD TO FORMULARY Covered 04/11/2016 fluconazole fluconazole ADD TO FORMULARY Covered 04/11/2016 fluconazole fluconazole ADD TO FORMULARY Covered 04/11/2016 fluconazole fluconazole CHANGE UM: AGE 04/11/2016 fluconazole fluconazole ADD TO FORMULARY 04/11/2016 DIFLUCAN fluconazole ADD TO FORMULARY 04/11/2016 DIFLUCAN fluconazole ADD UM: AGE 04/11/2016 chloroquine phosphate chloroquine phosphate CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 chloroquine phosphate chloroquine phosphate CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 hydroxychloroqui hydroxychloroquine sulfate ne sulfate 04/11/2016 DARAPRIM 04/11/2016 2 / Day 0 to 12 yrs old 2 / Day Up to 12 yrs old Covered Non-Formulary Covered Up to 12 yrs old ADD TO FORMULARY Covered pyrimethamine ADD UM: AUTHORIZATION PA applies DARAPRIM pyrimethamine ADD TO FORMULARY Covered 04/11/2016 metronidazole metronidazole ADD TO FORMULARY Covered 04/11/2016 valganciclovir hcl valganciclovir hcl ADD TO FORMULARY Covered 04/11/2016 valganciclovir hcl valganciclovir hcl ADD UM: AUTHORIZATION PA applies 04/11/2016 valganciclovir hcl valganciclovir hcl ADD UM: QUANTITY 2 / Day 04/11/2016 valganciclovir hcl valganciclovir hcl CHANGE UM: QUANTITY 04/11/2016 entecavir entecavir ADD TO FORMULARY Covered 04/11/2016 entecavir entecavir ADD TO FORMULARY Covered 2 / Day 2 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 623 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 2 / Day 2 / Day 04/11/2016 acyclovir acyclovir CHANGE UM: QUANTITY 04/11/2016 acyclovir acyclovir ADD TO FORMULARY Covered 04/11/2016 acyclovir acyclovir ADD UM: QUANTITY 2 / Day 04/11/2016 acyclovir acyclovir CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 acyclovir acyclovir CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 valacyclovir valacyclovir hcl CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 valacyclovir valacyclovir hcl ADD TO FORMULARY 04/11/2016 valacyclovir valacyclovir hcl CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 famciclovir famciclovir CHANGE UM: QUANTITY 3 / Day 3 / Day 04/11/2016 famciclovir famciclovir CHANGE UM: QUANTITY 3 / Day 3 / Day 04/11/2016 famciclovir famciclovir ADD TO FORMULARY 04/11/2016 famciclovir famciclovir CHANGE UM: QUANTITY 3 / Day 3 / Day 04/11/2016 TAMIFLU oseltamivir phosphate CHANGE UM: AGE 0 to 12 yrs old Up to 12 yrs old 04/11/2016 TAMIFLU oseltamivir phosphate CHANGE UM: CUSTOM 04/11/2016 TAMIFLU oseltamivir phosphate CHANGE UM: QUANTITY 04/11/2016 RELENZA zanamivir ADD UM: AGE 04/11/2016 RELENZA zanamivir CHANGE UM: QUANTITY 0.056 / day 0.0556 / Day 04/11/2016 FLUMADINE rimantadine hcl ADD TO FORMULARY Non-Formulary Covered 04/11/2016 temozolomide temozolomide ADD TO FORMULARY Covered 04/11/2016 temozolomide temozolomide ADD UM: AUTHORIZATION PA applies 04/11/2016 temozolomide temozolomide ADD TO FORMULARY Covered 04/11/2016 temozolomide temozolomide ADD UM: AUTHORIZATION PA applies 04/11/2016 temozolomide temozolomide ADD UM: AUTHORIZATION PA applies 04/11/2016 temozolomide temozolomide ADD TO FORMULARY Covered Covered Covered Max 120 per 180 Max 120 Mls per days 180 days 60 / rx 60 / Rx At least 5 yrs old BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 624 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 temozolomide temozolomide ADD UM: AUTHORIZATION PA applies 04/11/2016 temozolomide temozolomide ADD TO FORMULARY Covered 04/11/2016 temozolomide temozolomide ADD UM: AUTHORIZATION PA applies 04/11/2016 temozolomide temozolomide ADD TO FORMULARY Covered 04/11/2016 temozolomide temozolomide ADD UM: AUTHORIZATION PA applies 04/11/2016 temozolomide temozolomide ADD TO FORMULARY Covered 04/11/2016 capecitabine capecitabine ADD UM: AUTHORIZATION PA applies 04/11/2016 capecitabine capecitabine ADD TO FORMULARY Covered 04/11/2016 capecitabine capecitabine ADD TO FORMULARY Covered 04/11/2016 capecitabine capecitabine ADD UM: AUTHORIZATION PA applies 04/11/2016 ERIVEDGE vismodegib CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 XTANDI enzalutamide CHANGE UM: QUANTITY 4 / Day 4 / Day 04/11/2016 ZYTIGA abiraterone acetate CHANGE UM: QUANTITY 4 / Day 4 / Day 04/11/2016 anastrozole anastrozole ADD TO FORMULARY Covered 04/11/2016 anastrozole anastrozole ADD UM: GENDER Female 04/11/2016 letrozole letrozole 04/11/2016 megestrol acetate megestrol acetate ADD UM: GENDER Female 04/11/2016 megestrol acetate megestrol acetate ADD TO FORMULARY Covered 04/11/2016 tamoxifen citrate tamoxifen citrate CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 tamoxifen citrate tamoxifen citrate CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 REVLIMID lenalidomide CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 REVLIMID lenalidomide CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 REVLIMID lenalidomide CHANGE UM: QUANTITY 1 / Day 1 / Day CHANGE UM: QUANTITY 1 / Day 1 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 625 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 REVLIMID lenalidomide CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 JAKAFI ruxolitinib phosphate CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 JAKAFI ruxolitinib phosphate CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 JAKAFI ruxolitinib phosphate CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 JAKAFI ruxolitinib phosphate CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 JAKAFI ruxolitinib phosphate CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 AFINITOR everolimus CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 AFINITOR everolimus CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 AFINITOR everolimus CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 AFINITOR DISPERZ everolimus CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 AFINITOR DISPERZ everolimus CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 AFINITOR DISPERZ everolimus CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 isosorbide dinitrate isosorbide dinitrate ADD TO FORMULARY Covered 04/11/2016 isosorbide dinitrate isosorbide dinitrate ADD TO FORMULARY Covered 04/11/2016 isosorbide dinitrate isosorbide dinitrate ADD TO FORMULARY Covered 04/11/2016 isosorbide mononitrate er isosorbide mononitrate CHANGE UM: QUANTITY 04/11/2016 isosorbide mononitrate er isosorbide mononitrate ADD TO FORMULARY 04/11/2016 isosorbide mononitrate er isosorbide mononitrate CHANGE UM: QUANTITY 1 / Day 1 / Day Covered 1 / Day 1 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 626 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 isosorbide mononitrate er isosorbide mononitrate ADD TO FORMULARY Covered 04/11/2016 isosorbide mononitrate er isosorbide mononitrate CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 nitroglycerin patch nitroglycerin CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 minitran nitroglycerin CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 nitroglycerin patch nitroglycerin CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 minitran nitroglycerin CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 nitroglycerin patch nitroglycerin CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 minitran nitroglycerin CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 nitroglycerin patch nitroglycerin CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 minitran nitroglycerin CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 disopyramide phosphate disopyramide phosphate CHANGE UM: AGE 0 to 64 yrs old Up to 64 yrs old 04/11/2016 flecainide acetate flecainide acetate ADD TO FORMULARY Covered 04/11/2016 flecainide acetate flecainide acetate ADD TO FORMULARY Covered 04/11/2016 flecainide acetate flecainide acetate ADD TO FORMULARY Covered 04/11/2016 sotalol sotalol hcl CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 sorine sotalol hcl CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 sotalol af sotalol hcl CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 sorine sotalol hcl CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 sotalol sotalol hcl CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 sotalol af sotalol hcl CHANGE UM: QUANTITY 2 / Day 2 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 627 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 sotalol sotalol hcl CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 sorine sotalol hcl CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 sotalol af sotalol hcl CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 sorine sotalol hcl CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 sotalol sotalol hcl CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 amiodarone hcl amiodarone hcl 04/11/2016 cholestyramine cholestyramine (with sugar) CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 cholestyramine light cholestyramine/aspartame CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 colestipol hcl colestipol hcl ADD TO FORMULARY Covered 04/11/2016 colestipol hcl colestipol hcl ADD TO FORMULARY Covered 04/11/2016 fenofibric acid fenofibric acid (choline) ADD TO FORMULARY Covered 04/11/2016 fenofibric acid fenofibric acid (choline) CHANGE UM: QUANTITY 04/11/2016 fenofibric acid fenofibric acid (choline) ADD TO FORMULARY 04/11/2016 fenofibric acid fenofibric acid (choline) CHANGE UM: QUANTITY 04/11/2016 fenofibric acid fenofibric acid 04/11/2016 fenofibrate fenofibrate nanocrystallized CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 fenofibrate fenofibrate CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 fenofibrate fenofibrate ADD TO FORMULARY Covered 04/11/2016 fenofibrate fenofibrate nanocrystallized ADD UM: QUANTITY 1 / Day 04/11/2016 fenofibrate fenofibrate nanocrystallized CHANGE UM: QUANTITY 04/11/2016 fenofibrate fenofibrate nanocrystallized ADD TO FORMULARY 04/11/2016 fenofibrate fenofibrate 04/11/2016 fenofibrate fenofibrate,micronized ADD TO FORMULARY 04/11/2016 fenofibrate fenofibrate,micronized CHANGE UM: QUANTITY ADD TO FORMULARY Covered 1 / Day Covered 1 / Day ADD TO FORMULARY CHANGE UM: QUANTITY 1 / Day 1 / Day Covered 1 / Day 1 / Day Covered 1 / Day 1 / Day Covered 1 / Day 1 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 628 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 fenofibrate fenofibrate,micronized 04/11/2016 gemfibrozil gemfibrozil ADD TO FORMULARY Covered 04/11/2016 gemfibrozil gemfibrozil ADD UM: QUANTITY 2 / Day 04/11/2016 gemfibrozil gemfibrozil CHANGE UM: QUANTITY 04/11/2016 atorvastatin calcium atorvastatin calcium ADD TO FORMULARY 04/11/2016 atorvastatin calcium atorvastatin calcium CHANGE UM: QUANTITY 04/11/2016 atorvastatin calcium atorvastatin calcium ADD UM: QUANTITY 04/11/2016 atorvastatin calcium atorvastatin calcium CHANGE UM: QUANTITY 04/11/2016 atorvastatin calcium atorvastatin calcium ADD TO FORMULARY 04/11/2016 atorvastatin calcium atorvastatin calcium CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 atorvastatin calcium atorvastatin calcium CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 fluvastatin sodium fluvastatin sodium CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 fluvastatin sodium fluvastatin sodium CHANGE UM: QUANTITY 2 / Day 1 / Day 04/11/2016 lovastatin lovastatin CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 lovastatin lovastatin ADD TO FORMULARY 04/11/2016 lovastatin lovastatin CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 lovastatin lovastatin CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 pravastatin sodium pravastatin sodium 2 / Day 2 / Day Covered 1 / Day 1 / Day 1 / Day 1 / Day 1 / Day Covered Covered ADD TO FORMULARY Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 629 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 pravastatin sodium pravastatin sodium ADD UM: QUANTITY 1 / Day 04/11/2016 pravastatin sodium pravastatin sodium CHANGE UM: QUANTITY 04/11/2016 pravastatin sodium pravastatin sodium ADD UM: QUANTITY 04/11/2016 pravastatin sodium pravastatin sodium CHANGE UM: QUANTITY 04/11/2016 pravastatin sodium pravastatin sodium ADD TO FORMULARY 04/11/2016 pravastatin sodium pravastatin sodium CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 pravastatin sodium pravastatin sodium CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 simvastatin simvastatin ADD TO FORMULARY Covered 04/11/2016 simvastatin simvastatin ADD UM: QUANTITY 1 / Day 04/11/2016 simvastatin simvastatin CHANGE UM: QUANTITY 04/11/2016 simvastatin simvastatin ADD UM: QUANTITY 04/11/2016 simvastatin simvastatin CHANGE UM: QUANTITY 04/11/2016 simvastatin simvastatin ADD TO FORMULARY Covered 04/11/2016 simvastatin simvastatin ADD TO FORMULARY Covered 04/11/2016 simvastatin simvastatin ADD UM: QUANTITY 1 / Day 04/11/2016 simvastatin simvastatin CHANGE UM: QUANTITY 04/11/2016 simvastatin simvastatin ADD UM: QUANTITY 04/11/2016 simvastatin simvastatin CHANGE UM: QUANTITY 04/11/2016 simvastatin simvastatin ADD TO FORMULARY Covered 04/11/2016 NIASPAN niacin ADD UM: QUANTITY 4 / Day 1 / Day 1 / Day 1 / Day 1 / Day 1 / Day Covered 1 / Day 1 / Day 1 / Day 1 / Day 1 / Day 1 / Day 1 / Day 1 / Day 1 / Day 1 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 630 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value Non-Formulary Covered 04/11/2016 NIASPAN niacin ADD TO FORMULARY 04/11/2016 niacin er niacin ADD UM: QUANTITY 3 / Day 04/11/2016 niacin er niacin ADD TO FORMULARY Covered 04/11/2016 niacin er niacin ADD TO FORMULARY Covered 04/11/2016 niacin er niacin ADD UM: QUANTITY 2 / Day 04/11/2016 ZETIA ezetimibe 04/11/2016 omega-3 acid ethyl esters omega-3 acid ethyl esters ADD TO FORMULARY Covered 04/11/2016 omega-3 acid ethyl esters omega-3 acid ethyl esters ADD UM: AUTHORIZATION PA applies 04/11/2016 amlodipine besylatebenazepril amlodipine besylate/benazepril hcl ADD TO FORMULARY Covered 04/11/2016 amlodipine besylatebenazepril amlodipine besylate/benazepril hcl CHANGE UM: QUANTITY 04/11/2016 amlodipine besylatebenazepril amlodipine besylate/benazepril hcl ADD TO FORMULARY Covered 04/11/2016 amlodipine besylatebenazepril amlodipine besylate/benazepril hcl ADD UM: QUANTITY 1 / Day 04/11/2016 amlodipine besylatebenazepril amlodipine besylate/benazepril hcl CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 amlodipine besylatebenazepril amlodipine besylate/benazepril hcl CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 amlodipine besylatebenazepril amlodipine besylate/benazepril hcl ADD TO FORMULARY CHANGE UM: QUANTITY 1 / Day 1 / Day 1 / Day 1 / Day Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 631 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 1 / Day 1 / Day 04/11/2016 amlodipine besylatebenazepril amlodipine besylate/benazepril hcl CHANGE UM: QUANTITY 04/11/2016 amlodipine besylatebenazepril amlodipine besylate/benazepril hcl ADD TO FORMULARY 04/11/2016 amlodipine besylatebenazepril amlodipine besylate/benazepril hcl CHANGE UM: QUANTITY 04/11/2016 amlodipine besylatebenazepril amlodipine besylate/benazepril hcl ADD TO FORMULARY Covered 04/11/2016 amlodipine besylatebenazepril amlodipine besylate/benazepril hcl ADD UM: QUANTITY 1 / Day 04/11/2016 amlodipine besylatebenazepril amlodipine besylate/benazepril hcl CHANGE UM: QUANTITY 04/11/2016 amlodipine besylatebenazepril amlodipine besylate/benazepril hcl ADD TO FORMULARY 04/11/2016 benazepril hcl benazepril hcl CHANGE UM: QUANTITY 04/11/2016 benazepril hcl benazepril hcl ADD TO FORMULARY Covered 04/11/2016 benazepril hcl benazepril hcl ADD UM: QUANTITY 1.5 / Day 04/11/2016 benazepril hcl benazepril hcl CHANGE UM: QUANTITY 04/11/2016 benazepril hcl benazepril hcl ADD UM: QUANTITY 04/11/2016 benazepril hcl benazepril hcl CHANGE UM: QUANTITY 04/11/2016 benazepril hcl benazepril hcl ADD TO FORMULARY Covered 04/11/2016 benazepril hcl benazepril hcl ADD UM: QUANTITY 2 / Day 04/11/2016 benazepril hcl benazepril hcl CHANGE UM: QUANTITY Covered 1 / Day 1 / Day 1 / Day 1 / Day Covered 1.5 / day 1.5 / day 1.5 / Day 1.5 / Day 1.5 / Day 1.5 / day 2 / Day 1.5 / Day 2 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 632 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name benazepril hcl Type of Change Previous Value 04/11/2016 benazepril hcl 04/11/2016 enalapril maleate enalapril maleate CHANGE UM: QUANTITY 04/11/2016 enalapril maleate enalapril maleate ADD TO FORMULARY 04/11/2016 enalapril maleate enalapril maleate CHANGE UM: QUANTITY 1.5 / day 1.5 / Day 04/11/2016 enalapril maleate enalapril maleate CHANGE UM: QUANTITY 1.5 / day 1.5 / Day 04/11/2016 enalapril maleate enalapril maleate ADD TO FORMULARY 04/11/2016 enalapril maleate enalapril maleate CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 EPANED CHANGE UM: AGE 0 to 12 yrs old Up to 12 yrs old 04/11/2016 fosinopril sodium fosinopril sodium ADD TO FORMULARY Covered 04/11/2016 fosinopril sodium fosinopril sodium ADD UM: QUANTITY 1.5 / Day 04/11/2016 fosinopril sodium fosinopril sodium CHANGE UM: QUANTITY 04/11/2016 fosinopril sodium fosinopril sodium ADD TO FORMULARY Covered 04/11/2016 fosinopril sodium fosinopril sodium ADD UM: QUANTITY 1.5 / Day 04/11/2016 fosinopril sodium fosinopril sodium CHANGE UM: QUANTITY 04/11/2016 fosinopril sodium fosinopril sodium ADD UM: QUANTITY 04/11/2016 fosinopril sodium fosinopril sodium CHANGE UM: QUANTITY 04/11/2016 fosinopril sodium fosinopril sodium ADD TO FORMULARY 04/11/2016 lisinopril lisinopril CHANGE UM: QUANTITY 04/11/2016 lisinopril lisinopril ADD TO FORMULARY Covered 04/11/2016 lisinopril lisinopril ADD UM: QUANTITY 1.5 / Day 04/11/2016 lisinopril lisinopril CHANGE UM: QUANTITY 04/11/2016 lisinopril lisinopril ADD TO FORMULARY Covered 04/11/2016 lisinopril lisinopril ADD UM: QUANTITY 1.5 / Day 04/11/2016 lisinopril lisinopril CHANGE UM: QUANTITY 04/11/2016 lisinopril lisinopril ADD TO FORMULARY enalapril maleate ADD TO FORMULARY New Value Covered 1.5 / day 1.5 / Day Covered Covered 1.5 / day 1.5 / day 1.5 / Day 1.5 / Day 2 / Day 2 / Day 2 / Day Covered 1.5 / day 1.5 / day 1.5 / day 1.5 / Day 1.5 / Day 1.5 / Day Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 633 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 lisinopril lisinopril ADD UM: QUANTITY 1.5 / Day 04/11/2016 lisinopril lisinopril CHANGE UM: QUANTITY 04/11/2016 lisinopril lisinopril ADD TO FORMULARY Covered 04/11/2016 lisinopril lisinopril ADD TO FORMULARY Covered 04/11/2016 lisinopril lisinopril CHANGE UM: QUANTITY 04/11/2016 lisinopril lisinopril ADD TO FORMULARY Covered 04/11/2016 lisinopril lisinopril ADD UM: QUANTITY 2 / Day 04/11/2016 lisinopril lisinopril CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 perindopril erbumine perindopril erbumine CHANGE UM: QUANTITY 1.5 / day 1.5 / Day 04/11/2016 perindopril erbumine perindopril erbumine CHANGE UM: QUANTITY 1.5 / day 1.5 / Day 04/11/2016 quinapril hcl quinapril hcl CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 quinapril hcl quinapril hcl ADD TO FORMULARY 04/11/2016 quinapril hcl quinapril hcl CHANGE UM: QUANTITY 04/11/2016 quinapril hcl quinapril hcl ADD TO FORMULARY 04/11/2016 quinapril hcl quinapril hcl CHANGE UM: QUANTITY 04/11/2016 quinapril hcl quinapril hcl ADD TO FORMULARY Covered 04/11/2016 quinapril hcl quinapril hcl ADD TO FORMULARY Covered 04/11/2016 quinapril hcl quinapril hcl CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 ramipril ramipril CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 ramipril ramipril CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 ramipril ramipril ADD UM: QUANTITY 04/11/2016 ramipril ramipril CHANGE UM: QUANTITY 04/11/2016 ramipril ramipril ADD UM: QUANTITY 1.5 / day 1.5 / day 1.5 / Day 1.5 / Day Covered 1 / Day 1 / Day Covered 1 / Day 1 / Day 1 / Day 1 / Day 1 / Day 1 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 634 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 ramipril ramipril CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 trandolapril trandolapril CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 trandolapril trandolapril CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 trandolapril trandolapril CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 enalaprilenalapril hydrochlorothiazi maleate/hydrochlorothiazide de CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 enalaprilenalapril hydrochlorothiazi maleate/hydrochlorothiazide de CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 lisinoprillisinopril/hydrochlorothiazide hydrochlorothiazi de CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 lisinoprillisinopril/hydrochlorothiazide hydrochlorothiazi de ADD TO FORMULARY Covered 04/11/2016 lisinoprillisinopril/hydrochlorothiazide hydrochlorothiazi de ADD TO FORMULARY Covered 04/11/2016 lisinoprillisinopril/hydrochlorothiazide hydrochlorothiazi de CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 lisinoprillisinopril/hydrochlorothiazide hydrochlorothiazi de,lisinopril-hctz CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 lisinoprillisinopril/hydrochlorothiazide hydrochlorothiazi de ADD TO FORMULARY 04/11/2016 irbesartanirbesartan/hydrochlorothiazi hydrochlorothiazi de de CHANGE UM: QUANTITY Covered 1 / Day 1 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 635 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 irbesartanirbesartan/hydrochlorothiazi hydrochlorothiazi de de CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 losartanlosartan hydrochlorothiazi potassium/hydrochlorothiazi de de CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 losartanlosartan hydrochlorothiazi potassium/hydrochlorothiazi de de CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 losartanlosartan hydrochlorothiazi potassium/hydrochlorothiazi de de CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 irbesartan irbesartan ADD TO FORMULARY 04/11/2016 irbesartan irbesartan CHANGE UM: QUANTITY 04/11/2016 irbesartan irbesartan ADD TO FORMULARY 04/11/2016 irbesartan irbesartan CHANGE UM: QUANTITY 04/11/2016 irbesartan irbesartan ADD TO FORMULARY 04/11/2016 irbesartan irbesartan CHANGE UM: QUANTITY 04/11/2016 losartan potassium losartan potassium ADD TO FORMULARY Covered 04/11/2016 losartan potassium losartan potassium ADD UM: QUANTITY 1 / Day 04/11/2016 losartan potassium losartan potassium CHANGE UM: QUANTITY 04/11/2016 losartan potassium losartan potassium ADD TO FORMULARY Covered 04/11/2016 losartan potassium losartan potassium ADD UM: QUANTITY 1 / Day 04/11/2016 losartan potassium losartan potassium CHANGE UM: QUANTITY Covered 1 / Day 1 / Day Covered 1 / Day 1 / Day Covered 1 / Day 1 / Day 1 / Day 1 / Day 1 / Day 1 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 636 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 losartan potassium losartan potassium ADD TO FORMULARY Covered 04/11/2016 losartan potassium losartan potassium ADD UM: QUANTITY 1 / Day 04/11/2016 losartan potassium losartan potassium CHANGE UM: QUANTITY 04/11/2016 valsartan valsartan ADD TO FORMULARY Covered 04/11/2016 valsartan valsartan ADD TO FORMULARY Covered 04/11/2016 valsartan valsartan ADD TO FORMULARY Covered 04/11/2016 atenololchlorthalidone atenolol/chlorthalidone ADD TO FORMULARY Covered 04/11/2016 bisoprololbisoprolol hydrochlorothiazi fumarate/hydrochlorothiazid de e CHANGE UM: QUANTITY 1.5 / day 1.5 / Day 04/11/2016 bisoprololbisoprolol hydrochlorothiazi fumarate/hydrochlorothiazid de e CHANGE UM: QUANTITY 1.5 / day 1.5 / Day 04/11/2016 bisoprololbisoprolol hydrochlorothiazi fumarate/hydrochlorothiazid de,bisoprolol e fumarate-hctz CHANGE UM: QUANTITY 2 / Day 1.5 / Day 04/11/2016 clonidine hcl clonidine hcl ADD TO FORMULARY Covered 04/11/2016 clonidine hcl clonidine hcl ADD TO FORMULARY Covered 04/11/2016 clonidine hcl clonidine hcl ADD TO FORMULARY Covered 04/11/2016 guanfacine hcl guanfacine hcl ADD TO FORMULARY Covered 04/11/2016 guanfacine hcl guanfacine hcl CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 guanfacine hcl guanfacine hcl CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 doxazosin mesylate doxazosin mesylate 1 / Day ADD TO FORMULARY 1 / Day Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 637 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 1 / Day 1 / Day 04/11/2016 doxazosin mesylate doxazosin mesylate CHANGE UM: QUANTITY 04/11/2016 doxazosin mesylate doxazosin mesylate ADD TO FORMULARY 04/11/2016 doxazosin mesylate doxazosin mesylate CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 doxazosin mesylate doxazosin mesylate CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 doxazosin mesylate doxazosin mesylate ADD TO FORMULARY 04/11/2016 doxazosin mesylate doxazosin mesylate CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 prazosin hcl prazosin hcl CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 prazosin hcl prazosin hcl CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 prazosin hcl prazosin hcl CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 terazosin hcl terazosin hcl CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 terazosin hcl terazosin hcl CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 terazosin hcl terazosin hcl CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 terazosin hcl terazosin hcl CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 LETAIRIS ambrisentan CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 LETAIRIS ambrisentan ADD UM: AUTHORIZATION PA applies 04/11/2016 LETAIRIS ambrisentan ADD TO FORMULARY Covered 04/11/2016 LETAIRIS ambrisentan CHANGE UM: QUANTITY 04/11/2016 LETAIRIS ambrisentan ADD UM: AUTHORIZATION PA applies 04/11/2016 LETAIRIS ambrisentan ADD TO FORMULARY Covered 04/11/2016 TRACLEER bosentan CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 TRACLEER bosentan CHANGE UM: QUANTITY 2 / Day 2 / Day Covered Covered 1 / Day 1 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 638 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 sildenafil sildenafil citrate ADD TO FORMULARY Covered 04/11/2016 sildenafil sildenafil citrate ADD UM: AUTHORIZATION PA applies 04/11/2016 ADCIRCA tadalafil CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 ADEMPAS riociguat CHANGE UM: QUANTITY 3 / Day 3 / Day 04/11/2016 ADEMPAS riociguat CHANGE UM: QUANTITY 3 / Day 3 / Day 04/11/2016 ADEMPAS riociguat CHANGE UM: QUANTITY 3 / Day 3 / Day 04/11/2016 ADEMPAS riociguat CHANGE UM: QUANTITY 3 / Day 3 / Day 04/11/2016 ADEMPAS riociguat CHANGE UM: QUANTITY 3 / Day 3 / Day 04/11/2016 TEKTURNA aliskiren hemifumarate CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 TEKTURNA aliskiren hemifumarate CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 TEKTURNA HCT aliskiren CHANGE UM: QUANTITY hemifumarate/hydrochlorothi azide 1 / Day 1 / Day 04/11/2016 TEKTURNA HCT aliskiren CHANGE UM: QUANTITY hemifumarate/hydrochlorothi azide 1 / Day 1 / Day 04/11/2016 TEKTURNA HCT aliskiren CHANGE UM: QUANTITY hemifumarate/hydrochlorothi azide 1 / Day 1 / Day 04/11/2016 TEKTURNA HCT aliskiren CHANGE UM: QUANTITY hemifumarate/hydrochlorothi azide 1 / Day 1 / Day 04/11/2016 carvedilol carvedilol ADD TO FORMULARY Covered 04/11/2016 carvedilol carvedilol ADD TO FORMULARY Covered 04/11/2016 labetalol hcl labetalol hcl ADD TO FORMULARY Covered 04/11/2016 labetalol hcl labetalol hcl ADD TO FORMULARY Covered 04/11/2016 atenolol atenolol ADD TO FORMULARY Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 639 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 bisoprolol fumarate bisoprolol fumarate CHANGE UM: QUANTITY 1.5 / day 1.5 / Day 04/11/2016 bisoprolol fumarate bisoprolol fumarate CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 metoprolol succinate metoprolol succinate ADD UM: QUANTITY 04/11/2016 metoprolol succinate metoprolol succinate CHANGE UM: QUANTITY 04/11/2016 metoprolol succinate metoprolol succinate ADD TO FORMULARY Covered 04/11/2016 metoprolol succinate metoprolol succinate ADD TO FORMULARY Covered 04/11/2016 metoprolol succinate metoprolol succinate ADD UM: QUANTITY 1.5 / Day 04/11/2016 metoprolol succinate metoprolol succinate CHANGE UM: QUANTITY 1.5 / day 1.5 / Day 04/11/2016 metoprolol succinate metoprolol succinate CHANGE UM: QUANTITY 1.5 / day 1.5 / Day 04/11/2016 metoprolol succinate metoprolol succinate CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 metoprolol tartrate metoprolol tartrate CHANGE UM: QUANTITY 3 / Day 3 / Day 04/11/2016 metoprolol tartrate metoprolol tartrate ADD TO FORMULARY 04/11/2016 metoprolol tartrate metoprolol tartrate CHANGE UM: QUANTITY 04/11/2016 metoprolol tartrate metoprolol tartrate ADD TO FORMULARY Covered 04/11/2016 metoprolol tartrate metoprolol tartrate ADD TO FORMULARY Covered 1.5 / Day 1.5 / day 1.5 / Day Covered 3 / Day 3 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 640 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 metoprolol tartrate metoprolol tartrate ADD UM: QUANTITY 3 / Day 04/11/2016 metoprolol tartrate metoprolol tartrate CHANGE UM: QUANTITY 04/11/2016 nadolol nadolol ADD TO FORMULARY Covered 04/11/2016 nadolol nadolol ADD TO FORMULARY Covered 04/11/2016 nadolol nadolol ADD TO FORMULARY Covered 04/11/2016 propranolol hcl propranolol hcl ADD TO FORMULARY Covered 04/11/2016 propranolol hcl propranolol hcl ADD TO FORMULARY Covered 04/11/2016 HEMANGEOL propranolol hcl CHANGE UM: AGE 0 to 4 yrs old Up to 4 yrs old 04/11/2016 propranolol hcl propranolol hcl er,propranolol hcl CHANGE UM: QUANTITY 4 / Day 4 / Day 04/11/2016 propranolol hcl propranolol hcl er,propranolol hcl CHANGE UM: QUANTITY 3 / Day 3 / Day 04/11/2016 propranolol hcl propranolol hcl er,propranolol hcl CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 propranolol hcl er propranolol hcl CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 propranolol hcl er propranolol hcl ADD TO FORMULARY 04/11/2016 diltiazem hcl diltiazem hcl CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 diltiazem hcl diltiazem hcl CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 diltiazem hcl diltiazem hcl CHANGE UM: QUANTITY 4 / Day 4 / Day 04/11/2016 diltiazem hcl diltiazem hcl CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 diltiazem er diltiazem hcl CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 diltiazem er diltiazem hcl CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 diltiazem er diltiazem hcl CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 diltiazem er diltiazem hcl CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 diltiazem er diltiazem hcl CHANGE UM: QUANTITY 1 / Day 1 / Day 3 / Day 3 / Day Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 641 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 diltiazem er diltiazem hcl CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 diltiazem er diltiazem hcl CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 diltiazem er diltiazem hcl CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 diltiazem er diltiazem hcl CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 diltiazem 24hr diltiazem hcl er,diltiazem 24hr cd CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 diltiazem 24hr diltiazem hcl cd,diltiazem 24hr er CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 diltiazem 24hr diltiazem hcl er,diltiazem 24hr cd CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 diltiazem 24hr diltiazem hcl er,diltiazem er,diltiazem 24hr cd CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 diltiazem er diltiazem hcl CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 diltiazem 24hr er,diltiazem er diltiazem hcl CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 amlodipine besylate amlodipine besylate ADD UM: QUANTITY 04/11/2016 amlodipine besylate amlodipine besylate CHANGE UM: QUANTITY 04/11/2016 amlodipine besylate amlodipine besylate ADD TO FORMULARY Covered 04/11/2016 amlodipine besylate amlodipine besylate ADD TO FORMULARY Covered 04/11/2016 amlodipine besylate amlodipine besylate ADD UM: QUANTITY 1 / Day 1 / Day 1 / Day 1 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 642 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 1 / Day 1 / Day 04/11/2016 amlodipine besylate amlodipine besylate CHANGE UM: QUANTITY 04/11/2016 amlodipine besylate amlodipine besylate ADD TO FORMULARY Covered 04/11/2016 amlodipine besylate amlodipine besylate ADD UM: QUANTITY 1 / Day 04/11/2016 amlodipine besylate amlodipine besylate CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 felodipine er felodipine CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 felodipine er felodipine CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 felodipine er felodipine CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 isradipine isradipine CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 isradipine isradipine CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 nicardipine hcl nicardipine hcl CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 nicardipine hcl nicardipine hcl CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 nifedipine nifedipine CHANGE UM: QUANTITY 4 / Day 4 / Day 04/11/2016 nifedipine nifedipine ADD UM: AGE Up to 64 yrs old 04/11/2016 nifedipine nifedipine ADD TO FORMULARY Covered 04/11/2016 nifedipine nifedipine CHANGE UM: QUANTITY 04/11/2016 nifedipine er nifedipine ADD UM: QUANTITY 04/11/2016 nifedipine er nifedipine CHANGE UM: QUANTITY 04/11/2016 nifedipine er nifedipine ADD TO FORMULARY Covered 04/11/2016 nifedipine er nifedipine ADD UM: QUANTITY 1 / Day 04/11/2016 nifedipine er nifedipine CHANGE UM: QUANTITY 04/11/2016 nifedipine er nifedipine ADD TO FORMULARY Covered 04/11/2016 nifedipine er nifedipine ADD UM: QUANTITY 1 / Day 4 / Day 4 / Day 1 / Day 1 / Day 1 / Day 1 / Day 1 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 643 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 1 / Day 1 / Day 04/11/2016 nifedipine er nifedipine CHANGE UM: QUANTITY 04/11/2016 nifedipine er nifedipine ADD TO FORMULARY 04/11/2016 nifedipine er nifedipine CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 nifedipine er nifedipine CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 nifedipine er nifedipine CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 nimodipine nimodipine ADD TO FORMULARY Covered 04/11/2016 nimodipine nimodipine ADD UM: QUANTITY 1 / Day 04/11/2016 nimodipine nimodipine CHANGE UM: QUANTITY 04/11/2016 verapamil hcl verapamil hcl ADD TO FORMULARY 04/11/2016 verapamil er verapamil hcl CHANGE UM: QUANTITY 04/11/2016 verapamil er verapamil hcl ADD TO FORMULARY 04/11/2016 verapamil er verapamil hcl CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 verapamil er verapamil hcl CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 verapamil er pm verapamil hcl CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 verapamil sr,verapamil er verapamil hcl CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 verapamil sr,verapamil er verapamil hcl CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 verapamil er pm verapamil hcl CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 verapamil sr,verapamil er verapamil hcl CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 verapamil er pm verapamil hcl CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 EPIPEN JR 2PAK epinephrine CHANGE UM: QUANTITY 0.02 / day 0.02 / Day 04/11/2016 epinephrine epinephrine CHANGE UM: QUANTITY 0.6 / 30 Days 0.02 / Day 04/11/2016 epinephrine epinephrine CHANGE UM: QUANTITY 0.02 / day 0.02 / Day Covered 1 / Day 1 / Day Covered 1 / Day 1 / Day Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 644 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 midodrine hcl midodrine hcl CHANGE UM: QUANTITY 3 / Day 3 / Day 04/11/2016 midodrine hcl midodrine hcl CHANGE UM: QUANTITY 3 / Day 3 / Day 04/11/2016 midodrine hcl midodrine hcl CHANGE UM: QUANTITY 3 / Day 3 / Day 04/11/2016 spironolactone spironolactone CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 spironolactone spironolactone ADD TO FORMULARY 04/11/2016 spironolactone spironolactone CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 spironolactone spironolactone CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 acetazolamide acetazolamide ADD TO FORMULARY Covered 04/11/2016 furosemide furosemide ADD TO FORMULARY Covered 04/11/2016 furosemide furosemide ADD UM: QUANTITY 1 / Day 04/11/2016 furosemide furosemide CHANGE UM: QUANTITY 04/11/2016 furosemide furosemide ADD UM: QUANTITY 04/11/2016 furosemide furosemide CHANGE UM: QUANTITY 04/11/2016 furosemide furosemide ADD TO FORMULARY 04/11/2016 furosemide furosemide CHANGE UM: QUANTITY 04/11/2016 furosemide furosemide ADD UM: AGE Up to 12 yrs old 04/11/2016 furosemide furosemide ADD TO FORMULARY Covered 04/11/2016 torsemide torsemide CHANGE UM: QUANTITY 04/11/2016 torsemide torsemide ADD TO FORMULARY 04/11/2016 torsemide torsemide CHANGE UM: QUANTITY 04/11/2016 torsemide torsemide ADD TO FORMULARY 04/11/2016 torsemide torsemide CHANGE UM: QUANTITY 04/11/2016 torsemide torsemide ADD TO FORMULARY Covered 04/11/2016 torsemide torsemide ADD TO FORMULARY Covered 04/11/2016 torsemide torsemide CHANGE UM: QUANTITY Covered 1 / Day 1 / Day 1 / Day 1 / Day 1 / Day Covered 1 / Day 2 / Day 1 / Day 2 / Day Covered 4 / Day 4 / Day Covered 4 / Day 2 / Day 4 / Day 2 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 645 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 amiloride hcl amiloride hcl ADD TO FORMULARY 04/11/2016 amiloride hcl amiloride hcl CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 amilorideamiloride hydrochlorothiazi hcl/hydrochlorothiazide de,amiloride hclhctz CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 spironolactonehctz CHANGE UM: QUANTITY 3 / Day 3 / Day 04/11/2016 triamterenetriamterene/hydrochlorothiaz hydrochlorothiazi ide d 04/11/2016 chlorthalidone chlorthalidone CHANGE UM: QUANTITY 04/11/2016 chlorthalidone chlorthalidone ADD UM: QUANTITY 04/11/2016 chlorthalidone chlorthalidone CHANGE UM: QUANTITY 04/11/2016 chlorthalidone chlorthalidone ADD TO FORMULARY 04/11/2016 hydrochlorothiazi hydrochlorothiazide de CHANGE UM: QUANTITY 04/11/2016 hydrochlorothiazi hydrochlorothiazide de ADD TO FORMULARY Covered 04/11/2016 hydrochlorothiazi hydrochlorothiazide de ADD UM: QUANTITY 1 / Day 04/11/2016 hydrochlorothiazi hydrochlorothiazide de CHANGE UM: QUANTITY 04/11/2016 hydrochlorothiazi hydrochlorothiazide de ADD TO FORMULARY Covered 04/11/2016 hydrochlorothiazi hydrochlorothiazide de ADD UM: QUANTITY 1 / Day 04/11/2016 hydrochlorothiazi hydrochlorothiazide de CHANGE UM: QUANTITY spironolactone/hydrochlorot hiazide Covered ADD TO FORMULARY Covered 4 / Day 4 / Day 4 / Day 4 / Day 4 / Day Covered 1 / Day 1 / Day 1 / Day 1 / Day 1 / Day 1 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 646 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 hydrochlorothiazi hydrochlorothiazide de ADD TO FORMULARY Covered 04/11/2016 indapamide indapamide ADD TO FORMULARY Covered 04/11/2016 indapamide indapamide ADD UM: QUANTITY 1 / Day 04/11/2016 indapamide indapamide CHANGE UM: QUANTITY 04/11/2016 indapamide indapamide ADD TO FORMULARY 04/11/2016 indapamide indapamide CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 metolazone metolazone CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 metolazone metolazone ADD TO FORMULARY Covered 04/11/2016 metolazone metolazone ADD UM: QUANTITY 1 / Day 04/11/2016 metolazone metolazone CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 metolazone metolazone CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 hydroxyzine hcl hydroxyzine hcl ADD UM: AGE Up to 64 yrs old 04/11/2016 hydroxyzine hcl hydroxyzine hcl ADD TO FORMULARY Covered 04/11/2016 hydroxyzine hcl hydroxyzine hcl CHANGE UM: AGE 04/11/2016 hydroxyzine pamoate hydroxyzine pamoate ADD UM: AGE Up to 64 yrs old 04/11/2016 hydroxyzine pamoate hydroxyzine pamoate ADD TO FORMULARY Covered 04/11/2016 carbidopalevodopa carbidopa/levodopa CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 bromocriptine mesylate bromocriptine mesylate CHANGE UM: QUANTITY 6 / Day 6 / Day 04/11/2016 selegiline hcl selegiline hcl CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 amantadine amantadine hcl CHANGE UM: QUANTITY 4 / Day 4 / Day 04/11/2016 amantadine amantadine hcl CHANGE UM: QUANTITY 20 / Day 20 / Day 1 / Day 1 / Day Covered Up to 64 yrs old Up to 12 yrs old BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 647 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 pramipexole dihydrochloride pramipexole di-hcl ADD TO FORMULARY Covered 04/11/2016 pramipexole dihydrochloride pramipexole di-hcl ADD UM: QUANTITY 1 / Day 04/11/2016 pramipexole dihydrochloride pramipexole di-hcl CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 pramipexole dihydrochloride pramipexole di-hcl CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 pramipexole dihydrochloride pramipexole di-hcl ADD TO FORMULARY Covered 04/11/2016 pramipexole dihydrochloride pramipexole di-hcl ADD TO FORMULARY Covered 04/11/2016 pramipexole dihydrochloride pramipexole di-hcl CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 pramipexole dihydrochloride pramipexole di-hcl CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 pramipexole dihydrochloride pramipexole di-hcl ADD TO FORMULARY Covered 04/11/2016 pramipexole dihydrochloride pramipexole di-hcl ADD TO FORMULARY Covered 04/11/2016 pramipexole dihydrochloride pramipexole di-hcl CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 pramipexole dihydrochloride pramipexole di-hcl CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 pramipexole dihydrochloride pramipexole di-hcl ADD TO FORMULARY Covered 04/11/2016 ropinirole hcl ropinirole hcl ADD UM: QUANTITY 1 / Day 04/11/2016 ropinirole hcl ropinirole hcl CHANGE UM: QUANTITY 04/11/2016 ropinirole hcl ropinirole hcl ADD TO FORMULARY 1 / Day 1 / Day Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 648 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 ropinirole hcl ropinirole hcl ADD UM: QUANTITY 1 / Day 04/11/2016 ropinirole hcl ropinirole hcl CHANGE UM: QUANTITY 04/11/2016 ropinirole hcl ropinirole hcl ADD TO FORMULARY Covered 04/11/2016 ropinirole hcl ropinirole hcl ADD UM: QUANTITY 1 / Day 04/11/2016 ropinirole hcl ropinirole hcl CHANGE UM: QUANTITY 04/11/2016 ropinirole hcl ropinirole hcl ADD TO FORMULARY Covered 04/11/2016 ropinirole hcl ropinirole hcl ADD TO FORMULARY Covered 04/11/2016 ropinirole hcl ropinirole hcl ADD UM: QUANTITY 1 / Day 04/11/2016 ropinirole hcl ropinirole hcl CHANGE UM: QUANTITY 04/11/2016 ropinirole hcl ropinirole hcl ADD TO FORMULARY Covered 04/11/2016 ropinirole hcl ropinirole hcl ADD UM: QUANTITY 1 / Day 04/11/2016 ropinirole hcl ropinirole hcl CHANGE UM: QUANTITY 04/11/2016 ropinirole hcl ropinirole hcl ADD TO FORMULARY Covered 04/11/2016 ropinirole hcl ropinirole hcl ADD UM: QUANTITY 1 / Day 04/11/2016 ropinirole hcl ropinirole hcl CHANGE UM: QUANTITY 04/11/2016 ropinirole hcl ropinirole hcl ADD UM: QUANTITY 04/11/2016 ropinirole hcl ropinirole hcl CHANGE UM: QUANTITY 04/11/2016 ropinirole hcl ropinirole hcl ADD TO FORMULARY 04/11/2016 caffeine citrate caffeine citrated 04/11/2016 naratriptan hcl,naratriptan 04/11/2016 1 / Day 1 / Day 1 / Day 1 / Day 1 / Day 1 / Day 1 / Day 1 / Day 1 / Day 1 / Day 1 / Day 1 / Day 1 / Day Covered CHANGE UM: AGE 0 to 1 yrs old Up to 1 yrs old naratriptan hcl CHANGE UM: QUANTITY 0.3 / day 0.3 / Day naratriptan hcl,naratriptan naratriptan hcl CHANGE UM: QUANTITY 0.3 / day 0.3 / Day 04/11/2016 rizatriptan rizatriptan benzoate CHANGE UM: QUANTITY 0.3 / day 0.3 / Day 04/11/2016 rizatriptan rizatriptan benzoate CHANGE UM: QUANTITY 0.3 / day 0.3 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 649 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 rizatriptan rizatriptan benzoate CHANGE UM: QUANTITY 0.3 / day 0.3 / Day 04/11/2016 rizatriptan rizatriptan benzoate CHANGE UM: QUANTITY 0.3 / day 0.3 / Day 04/11/2016 sumatriptan succinate sumatriptan succinate CHANGE UM: QUANTITY 9 / 30 days 0.3 / Day 04/11/2016 sumatriptan succinate sumatriptan succinate CHANGE UM: QUANTITY 9 / 30 days 0.3 / Day 04/11/2016 sumatriptan succinate sumatriptan succinate CHANGE UM: QUANTITY 9 / 30 days 0.3 / Day 04/11/2016 sumatriptan succinate sumatriptan succinate CHANGE UM: QUANTITY 4 / 30 days 4 / 30 Days 04/11/2016 sumatriptan succinate sumatriptan succinate ADD UM: CUSTOM Max 8 Syringes per 30 Days. Cumulative across injectable Triptans 04/11/2016 zolmitriptan zolmitriptan ADD UM: STEP ST applies 04/11/2016 zolmitriptan zolmitriptan ADD TO FORMULARY Covered 04/11/2016 zolmitriptan zolmitriptan CHANGE UM: QUANTITY 04/11/2016 zolmitriptan zolmitriptan ADD UM: STEP 04/11/2016 zolmitriptan zolmitriptan CHANGE UM: QUANTITY 04/11/2016 zolmitriptan zolmitriptan ADD TO FORMULARY Covered 04/11/2016 zolmitriptan odt zolmitriptan ADD UM: STEP ST applies 04/11/2016 zolmitriptan odt zolmitriptan CHANGE UM: QUANTITY 0.3 / day 0.3 / Day 04/11/2016 zolmitriptan odt zolmitriptan CHANGE UM: QUANTITY 0.3 / day 0.3 / Day 04/11/2016 zolmitriptan odt zolmitriptan ADD UM: STEP 0.3 / day 0.3 / Day ST applies 0.3 / day 0.3 / Day ST applies BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 650 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change 04/11/2016 sumatriptan succinate sumatriptan succinate ADD UM: CUSTOM 04/11/2016 sumatriptan succinate sumatriptan succinate CHANGE UM: QUANTITY 04/11/2016 sumatriptan succinate sumatriptan succinate ADD UM: CUSTOM 04/11/2016 sumatriptan succinate sumatriptan succinate CHANGE UM: QUANTITY 04/11/2016 sumatriptan succinate sumatriptan succinate ADD UM: CUSTOM 04/11/2016 sumatriptan succinate sumatriptan succinate CHANGE UM: QUANTITY 04/11/2016 sumatriptan succinate sumatriptan succinate ADD UM: CUSTOM 04/11/2016 sumatriptan succinate sumatriptan succinate CHANGE UM: QUANTITY 04/11/2016 bupropion hcl sr bupropion hcl ADD UM: QUANTITY 04/11/2016 bupropion hcl sr,bupropion hcl er bupropion hcl CHANGE UM: QUANTITY 04/11/2016 bupropion hcl sr bupropion hcl ADD TO FORMULARY Previous Value New Value Max 8 Syringes per 30 Days. Cumulative across injectable Triptans 4 / 30 days 4 / 30 Days Max 8 Syringes per 30 Days. Cumulative across injectable Triptans 4 / 30 days 4 / 30 Days Max 8 Syringes per 30 Days. Cumulative across injectable Triptans 4 / 30 days 4 / 30 Days Max 8 Syringes per 30 Days. Cumulative across injectable Triptans 4 / 30 days 4 / 30 Days 2 / Day 2 / Day 2 / Day Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 651 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 NICOTROL NS nicotine CHANGE UM: QUANTITY 0.533 / day 0.333 / Day 04/11/2016 NICOTROL nicotine CHANGE UM: QUANTITY 0.034 / day 0.034 / Day 04/11/2016 nicotine patch nicotine CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 nicotine patch nicotine ADD UM: QUANTITY 04/11/2016 nicotine patch,nicotine nicotine CHANGE UM: QUANTITY 04/11/2016 nicotine patch nicotine ADD TO FORMULARY Covered 04/11/2016 nicotine patch nicotine ADD UM: QUANTITY 1 / Day 04/11/2016 nicotine patch nicotine CHANGE UM: QUANTITY 04/11/2016 nicotine patch nicotine ADD TO FORMULARY Covered 04/11/2016 nicotine patch nicotine ADD TO FORMULARY Covered 04/11/2016 nicotine patch nicotine ADD UM: QUANTITY 1 / Day 04/11/2016 nicotine patch nicotine CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 nts nicotine CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 nicotine gum nicotine polacrilex ADD TO FORMULARY Covered 04/11/2016 nicotine gum nicotine polacrilex ADD UM: QUANTITY 30 / Day 04/11/2016 nicotine gum nicotine polacrilex CHANGE UM: QUANTITY 30 / Day 30 / Day 04/11/2016 quit 2 nicotine polacrilex CHANGE UM: QUANTITY 30 / Day 30 / Day 04/11/2016 glimepiride glimepiride CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 glimepiride glimepiride ADD TO FORMULARY Covered 04/11/2016 glipizide glipizide ADD UM: QUANTITY 8 / Day 04/11/2016 glipizide glipizide CHANGE UM: QUANTITY 04/11/2016 glipizide glipizide ADD TO FORMULARY 04/11/2016 glipizide glipizide CHANGE UM: QUANTITY 1 / Day 1 / Day 1 / Day 8 / Day 1 / Day 1 / Day 8 / Day Covered 4 / Day 4 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 652 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 glipizide er,glipizide xl glipizide CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 glipizide er,glipizide xl glipizide CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 glipizide er,glipizide xl glipizide CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 glyburide glyburide CHANGE UM: QUANTITY 4 / Day 4 / Day 04/11/2016 glyburide glyburide CHANGE UM: QUANTITY 4 / Day 4 / Day 04/11/2016 glyburide glyburide ADD TO FORMULARY Covered 04/11/2016 glyburide glyburide ADD TO FORMULARY Covered 04/11/2016 glyburide glyburide CHANGE UM: QUANTITY 4 / Day 4 / Day 04/11/2016 glyburide micronized glyburide,micronized CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 glyburide micronized glyburide,micronized CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 glyburide micronized glyburide,micronized CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 TANZEUM albiglutide ADD UM: AUTHORIZATION 04/11/2016 TANZEUM albiglutide CHANGE UM: QUANTITY 4 / 28 Days 0.14286 / Day 04/11/2016 TANZEUM albiglutide CHANGE UM: QUANTITY 4 / 28 Days 0.14286 / Day 04/11/2016 VICTOZA 2-PAK liraglutide CHANGE UM: QUANTITY 0.134 / day 0.134 / Day 04/11/2016 VICTOZA 3-PAK liraglutide CHANGE UM: QUANTITY 0.134 / day 0.134 / Day 04/11/2016 JANUMET sitagliptin phosphate/metformin hcl CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 JANUMET sitagliptin phosphate/metformin hcl CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 JANUMET XR sitagliptin phosphate/metformin hcl CHANGE UM: QUANTITY 1 / Day 1 / Day PA applies BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 653 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 JANUMET XR sitagliptin phosphate/metformin hcl CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 JANUMET XR sitagliptin phosphate/metformin hcl CHANGE UM: QUANTITY 1 / Day 1 / Day 04/11/2016 HUMULIN 70-30 insulin nph human isophane/insulin regular, human ADD UM: CUSTOM 04/11/2016 HUMULIN 70-30 insulin nph human isophane/insulin regular, human CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 NOVOLIN 70-30 insulin nph human isophane/insulin regular, human,nph, human insulin isophane/insulin regular, human CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 NOVOLIN 70-30 insulin nph human isophane/insulin regular, human,nph, human insulin isophane/insulin regular, human ADD UM: CUSTOM 04/11/2016 HUMULIN 70/30 insulin nph human KWIKPEN isophane/insulin regular, human CHANGE UM: QUANTITY 0.667 / day 0.667 / Day 04/11/2016 HUMULIN 70/30 insulin nph human KWIKPEN isophane/insulin regular, human CHANGE UM: AGE 0 to 21 yrs old Up to 21 yrs old 04/11/2016 NOVOLIN N nph, human insulin isophane,insulin nph human isophane CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 NOVOLIN N nph, human insulin isophane,insulin nph human isophane ADD UM: CUSTOM 200 units per day 04/11/2016 HUMULIN N insulin nph human isophane ADD UM: CUSTOM 200 units per day 200 units per day 200 units per day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 654 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 HUMULIN N insulin nph human isophane CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 HUMULIN N KWIKPEN insulin nph human isophane CHANGE UM: AGE 0 to 21 yrs old Up to 21 yrs old 04/11/2016 HUMULIN N KWIKPEN insulin nph human isophane ADD UM: QUANTITY 04/11/2016 NOVOLIN R insulin regular, human CHANGE UM: QUANTITY 04/11/2016 NOVOLIN R insulin regular, human ADD UM: CUSTOM 04/11/2016 HUMULIN R insulin regular, human CHANGE UM: QUANTITY 04/11/2016 HUMULIN R insulin regular, human ADD UM: CUSTOM 200 units per day 04/11/2016 nicotine gum nicotine polacrilex ADD UM: QUANTITY 24 / Day 04/11/2016 nicotine gum nicotine polacrilex CHANGE UM: QUANTITY 04/11/2016 nicotine gum nicotine polacrilex ADD TO FORMULARY 04/11/2016 quit 4 nicotine polacrilex CHANGE UM: QUANTITY 04/11/2016 nicotine lozenge nicotine polacrilex ADD TO FORMULARY Covered 04/11/2016 nicotine lozenge nicotine polacrilex ADD UM: QUANTITY 20 / Day 04/11/2016 nicotine lozenge nicotine polacrilex CHANGE UM: QUANTITY 20 / Day 20 / Day 04/11/2016 stop smoking aid nicotine polacrilex CHANGE UM: QUANTITY 20 / Day 20 / Day 04/11/2016 quit 2 nicotine polacrilex CHANGE UM: QUANTITY 20 / Day 20 / Day 04/11/2016 nicotine lozenge nicotine polacrilex CHANGE UM: QUANTITY 20 / Day 20 / Day 04/11/2016 stop smoking aid nicotine polacrilex CHANGE UM: QUANTITY 20 / Day 20 / Day 04/11/2016 quit 4 nicotine polacrilex CHANGE UM: QUANTITY 20 / Day 20 / Day 04/11/2016 CHANTIX varenicline tartrate CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 CHANTIX varenicline tartrate CHANGE UM: CUSTOM Max 24 weeks therapy per year Max 2-12 week courses of therapy per year 0.667 / Day 2 / Day 2 / Day 200 units per day 2 / Day 24 / day 2 / Day 24 / Day Covered 24 / day 24 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 655 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 CHANTIX varenicline tartrate CHANGE UM: CUSTOM Max 24 weeks therapy per year Max 2-12 week courses of therapy per year 04/11/2016 CHANTIX varenicline tartrate CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 CHANTIX varenicline tartrate CHANGE UM: CUSTOM Max 24 weeks therapy per year Max 2-12 week courses of therapy per year 04/11/2016 CHANTIX varenicline tartrate CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 CHANTIX varenicline tartrate CHANGE UM: QUANTITY 2 / Day 2 / Day 04/11/2016 CHANTIX varenicline tartrate CHANGE UM: CUSTOM Max 24 weeks therapy per year Max 2-12 week courses of therapy per year 04/11/2016 donepezil hcl donepezil hcl ADD UM: QUANTITY 04/11/2016 donepezil hcl donepezil hcl CHANGE UM: QUANTITY 04/11/2016 donepezil hcl donepezil hcl ADD TO FORMULARY Covered 04/11/2016 donepezil hcl donepezil hcl ADD UM: AGE At least 40 yrs old 04/11/2016 donepezil hcl donepezil hcl ADD UM: QUANTITY 2 / Day 04/11/2016 donepezil hcl donepezil hcl CHANGE UM: QUANTITY 04/11/2016 donepezil hcl donepezil hcl ADD TO FORMULARY Covered 04/11/2016 donepezil hcl donepezil hcl ADD UM: AGE At least 40 yrs old 04/11/2016 NUVARING etonogestrel/ethinyl estradiol CHANGE UM: QUANTITY 04/11/2016 vcf nonoxynol 9 ADD UM: GENDER Female 04/11/2016 vcf nonoxynol 9 ADD TO FORMULARY Covered 04/11/2016 bekyree desogestrel-ethinyl estradiol/ethinyl estradiol ADD UM: GENDER Female 1 / Day 1 / Day 2 / Day 0.034 / day 1 / Day 2 / Day 0.034 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 656 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name 04/11/2016 bekyree desogestrel-ethinyl estradiol/ethinyl estradiol 04/11/2016 nikki 04/11/2016 Type of Change Previous Value New Value ADD TO FORMULARY Covered ethinyl estradiol/drospirenone ADD UM: GENDER Female nikki ethinyl estradiol/drospirenone ADD TO FORMULARY Covered 04/11/2016 kelnor 1-35 ethynodiol diacetate-ethinyl estradiol ADD UM: GENDER Female 04/11/2016 kelnor 1-35 ethynodiol diacetate-ethinyl estradiol ADD TO FORMULARY Covered 04/11/2016 vienva levonorgestrel-ethinyl estradiol ADD TO FORMULARY Covered 04/11/2016 vienva levonorgestrel-ethinyl estradiol ADD UM: GENDER Female 04/11/2016 cryselle norgestrel-ethinyl estradiol ADD TO FORMULARY Covered 04/11/2016 cryselle norgestrel-ethinyl estradiol ADD UM: GENDER Female 04/11/2016 SAFYRAL drospirenone/ethinyl estradiol/levomefolate calcium ADD UM: GENDER Female 04/11/2016 SAFYRAL drospirenone/ethinyl estradiol/levomefolate calcium ADD TO FORMULARY Covered 04/11/2016 kaitlib fe norethindrone-ethinyl estradiol/ferrous fumarate ADD UM: GENDER Female 04/11/2016 kaitlib fe norethindrone-ethinyl estradiol/ferrous fumarate ADD TO FORMULARY Covered 04/11/2016 kaitlib fe norethindrone-ethinyl estradiol/ferrous fumarate ADD UM: AUTHORIZATION PA applies 04/11/2016 blisovi fe norethindrone acetateethinyl estradiol/ferrous fumarate ADD UM: GENDER Female BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 657 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 blisovi fe norethindrone acetateethinyl estradiol/ferrous fumarate ADD TO FORMULARY Covered 04/11/2016 lomedia 24 fe norethindrone acetateethinyl estradiol/ferrous fumarate ADD UM: GENDER Female 04/11/2016 lomedia 24 fe norethindrone acetateethinyl estradiol/ferrous fumarate ADD TO FORMULARY Covered 04/11/2016 blisovi 24 fe norethindrone acetateethinyl estradiol/ferrous fumarate ADD UM: GENDER Female 04/11/2016 blisovi 24 fe norethindrone acetateethinyl estradiol/ferrous fumarate ADD TO FORMULARY Covered 04/11/2016 microgestin fe norethindrone acetateethinyl estradiol/ferrous fumarate ADD TO FORMULARY Covered 04/11/2016 microgestin fe norethindrone acetateethinyl estradiol/ferrous fumarate ADD UM: GENDER Female 04/11/2016 blisovi fe norethindrone acetateethinyl estradiol/ferrous fumarate ADD TO FORMULARY Covered 04/11/2016 blisovi fe norethindrone acetateethinyl estradiol/ferrous fumarate ADD UM: GENDER Female 04/11/2016 levonorgestreleth estradiol levonorgestrel-ethinyl estradiol ADD TO FORMULARY Covered 04/11/2016 levonorgestreleth estradiol levonorgestrel-ethinyl estradiol ADD UM: GENDER Female BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 658 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 norgestimateethinyl estradiol norgestimate-ethinyl estradiol ADD TO FORMULARY Covered 04/11/2016 norgestimateethinyl estradiol norgestimate-ethinyl estradiol ADD UM: GENDER Female 04/11/2016 tri-lo-sprintec norgestimate-ethinyl estradiol ADD TO FORMULARY Covered 04/11/2016 tri-lo-sprintec norgestimate-ethinyl estradiol ADD UM: GENDER Female 04/11/2016 trinessa lo norgestimate-ethinyl estradiol ADD UM: GENDER Female 04/11/2016 trinessa lo norgestimate-ethinyl estradiol ADD TO FORMULARY Covered 04/11/2016 tri-lo-estarylla norgestimate-ethinyl estradiol ADD UM: GENDER Female 04/11/2016 tri-lo-estarylla norgestimate-ethinyl estradiol ADD TO FORMULARY Covered 04/11/2016 tri-lo-marzia norgestimate-ethinyl estradiol ADD UM: GENDER Female 04/11/2016 tri-lo-marzia norgestimate-ethinyl estradiol ADD TO FORMULARY Covered 04/11/2016 xulane norelgestromin/ethinyl estradiol CHANGE UM: QUANTITY 0.143 / day 0.14286 / Day 04/11/2016 claravis isotretinoin CHANGE UM: QUANTITY 2 / 1 days 2 / Day 04/11/2016 zenatane isotretinoin ADD TO FORMULARY Covered 04/11/2016 myorisan isotretinoin ADD TO FORMULARY Covered 04/11/2016 claravis isotretinoin CHANGE UM: QUANTITY 04/11/2016 myorisan isotretinoin ADD TO FORMULARY 04/11/2016 myorisan isotretinoin CHANGE UM: QUANTITY 04/11/2016 myorisan isotretinoin ADD UM: AUTHORIZATION 2 / 1 days 2 / Day Covered 2 / 1 days 2 / Day PA applies BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 659 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 2 / 1 days 2 / Day 04/11/2016 zenatane isotretinoin CHANGE UM: QUANTITY 04/11/2016 zenatane isotretinoin ADD UM: AUTHORIZATION PA applies 04/11/2016 zenatane isotretinoin ADD TO FORMULARY Covered 04/11/2016 claravis isotretinoin CHANGE UM: QUANTITY 04/11/2016 zenatane isotretinoin ADD UM: AUTHORIZATION 04/11/2016 zenatane isotretinoin CHANGE UM: QUANTITY 04/11/2016 zenatane isotretinoin ADD TO FORMULARY 04/11/2016 claravis isotretinoin CHANGE UM: QUANTITY 04/11/2016 myorisan isotretinoin ADD UM: AUTHORIZATION PA applies 04/11/2016 myorisan isotretinoin ADD TO FORMULARY Covered 04/11/2016 myorisan isotretinoin CHANGE UM: QUANTITY 04/11/2016 zenatane isotretinoin ADD TO FORMULARY 04/11/2016 zenatane isotretinoin CHANGE UM: QUANTITY 04/11/2016 zenatane isotretinoin ADD UM: AUTHORIZATION PA applies 04/11/2016 SPIRIVA RESPIMAT tiotropium bromide CHANGE TIER Covered 04/11/2016 sleep aid diphenhydramine hcl ADD TO FORMULARY Covered 04/11/2016 sleep tablet diphenhydramine hcl ADD TO FORMULARY Covered 04/11/2016 nighttime sleep aid diphenhydramine hcl ADD TO FORMULARY Covered 04/11/2016 rest simply diphenhydramine hcl ADD TO FORMULARY Covered 04/11/2016 sleep tabs diphenhydramine hcl ADD TO FORMULARY Covered 04/11/2016 sleep ii diphenhydramine hcl ADD TO FORMULARY Covered 04/11/2016 sleep tabs diphenhydramine hcl ADD TO FORMULARY Covered 04/11/2016 simply sleep diphenhydramine hcl ADD TO FORMULARY Covered 1 / Day 2 / Day PA applies 1 / Day 2 / Day Covered 1 / Day 1 / Day 2 / Day 2 / Day Covered 1 / Day 2 / Day BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 660 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/11/2016 restfully sleep diphenhydramine hcl ADD TO FORMULARY Covered 04/11/2016 compoz diphenhydramine hcl ADD TO FORMULARY Covered 04/11/2016 nytol,nytol quickcaps diphenhydramine hcl ADD TO FORMULARY Covered 04/11/2016 nyt-time sleep diphenhydramine hcl ADD TO FORMULARY Covered 04/11/2016 compoz diphenhydramine hcl REMOVE FROM FORMULARY Covered Non-Formulary 04/11/2016 nytol,nytol quickcaps diphenhydramine hcl REMOVE FROM FORMULARY Covered Non-Formulary 04/11/2016 prenatal formula prenatal vitamin with ca no.131/ferrous fumarate/folic acid REMOVE FROM FORMULARY Covered Non-Formulary 04/11/2016 lactulose lactulose REMOVE FROM FORMULARY 04/11/2016 anastrozole,arimi anastrozole dex REMOVE UM: AUTHORIZATION 04/11/2016 megestrol acetate megestrol acetate REMOVE UM: AUTHORIZATION 04/11/2016 megestrol acetate megestrol acetate REMOVE UM: AUTHORIZATION 04/11/2016 tamoxifen citrate tamoxifen citrate REMOVE UM: AUTHORIZATION PA applies 04/11/2016 tamoxifen citrate tamoxifen citrate REMOVE UM: AUTHORIZATION PA applies 04/11/2016 taztia xt diltiazem hcl Non-Formulary PA applies CHANGE TIER Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 661 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value REMOVE FROM FORMULARY Covered Non-Formulary 04/12/2016 tri-vitamin with fluoride,vitamins a,c,d & fluoride,vitamins a,d,c & fluoride,triplevitamin wfluoride,trivitamin-fluoride pediatric multivitamins a,c,& d3 no.21 with sodium fluoride,fluoride/vitamins a,c,and d 04/12/2016 NATURETHROID thyroid,pork CHANGE TIER Covered 04/12/2016 hydrocortisone hydrocortisone CHANGE TIER Covered 04/12/2016 octreotide acetate octreotide acetate CHANGE TIER Covered 04/12/2016 sandostatin,octre octreotide acetate otide acetate REMOVE FROM FORMULARY Non-Formulary 04/12/2016 tolterodine tartrate er tolterodine tartrate CHANGE TIER Covered 04/12/2016 repaglinide repaglinide CHANGE TIER Covered 04/12/2016 ipratropiumalbuterol ipratropium bromide/albuterol sulfate CHANGE TIER Covered 04/12/2016 triamcinolone acetonide triamcinolone acetonide CHANGE TIER Covered 04/12/2016 tolterodine tartrate er tolterodine tartrate CHANGE TIER Covered 04/12/2016 desmopressin acetate desmopressin acetate (nonrefrigerated) CHANGE TIER Covered 04/12/2016 niacin er niacin CHANGE TIER Covered 04/12/2016 allergy relief chlorpheniramine maleate CHANGE TIER Covered 04/12/2016 montelukast sodium montelukast sodium CHANGE TIER Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 662 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/12/2016 liquitears polyvinyl alcohol CHANGE TIER Covered 04/12/2016 ondansetron odt ondansetron CHANGE TIER Covered 04/12/2016 theophylline anhydrous theophylline anhydrous CHANGE TIER Covered 04/12/2016 glimepiride glimepiride CHANGE TIER Covered 04/12/2016 prednisone prednisone CHANGE TIER Covered 04/12/2016 triamcinolone acetonide triamcinolone acetonide CHANGE TIER Covered 04/12/2016 aspirin ec aspirin CHANGE TIER Covered 04/12/2016 glyburidemetformin hcl glyburide/metformin hcl CHANGE TIER Covered 04/12/2016 morphine sulfate morphine sulfate er,morphine sulfate CHANGE TIER Covered 04/12/2016 hydrocortisone hydrocortisone CHANGE TIER Covered 04/12/2016 simvastatin simvastatin CHANGE TIER Covered 04/12/2016 hyoscyamine sulfate hyoscyamine sulfate CHANGE TIER Covered 04/12/2016 azelastine hcl azelastine hcl CHANGE TIER Covered 04/12/2016 prednisone prednisone CHANGE TIER Covered 04/12/2016 fluconazole fluconazole CHANGE TIER Covered 04/12/2016 calcitriol calcitriol CHANGE TIER Covered 04/12/2016 artificial tears polyvinyl alcohol CHANGE TIER Covered 04/12/2016 desmopressin acetate desmopressin acetate CHANGE TIER Covered 04/12/2016 3-day vaginal cream clotrimazole CHANGE TIER Covered 04/12/2016 glucosource lancing device,lancets CHANGE TIER Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 663 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/12/2016 alcohol prep pads alcohol antiseptic pads CHANGE TIER Covered 04/12/2016 onetouch suresoft lancing device/lancets,lancets CHANGE TIER Covered 04/12/2016 nasal allergy triamcinolone acetonide CHANGE TIER Covered 04/15/2016 LESCOL fluvastatin sodium REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 DIFLUCAN fluconazole REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 NIASPAN niacin REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 sleep diphenhydramine hcl aid,sominex,slee p ii,nighttime sleep aid,simply sleep,sleep-eze 3,sleep tabs,diphenhydra mine hcl,nytol,sleep tablet,alka-seltzer plus allergy,rest simply,restfully sleep,nyt-time sleep,nytol quickcaps,compo z REMOVE FROM FORMULARY 04/15/2016 METHADOSE methadone hcl REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 methadose methadone hcl REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 CHILDREN'S ibuprofen MOTRIN,MOTRI N REMOVE FROM FORMULARY Covered Non-Formulary Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 664 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/15/2016 INFANTS' ibuprofen MOTRIN,INFANT 'S MOTRIN REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 CHILDREN'S ZYRTEC REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 children's all day cetirizine hcl allergy 04/15/2016 TYLENOL EXTRA STRENGTH acetaminophen REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 TYLENOL acetaminophen REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 FLUMADINE rimantadine hcl REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 levothyroxine sodium levothyroxine sodium 04/15/2016 ciclodan ciclopirox 04/15/2016 STUART PRENATAL prenatal vitamins with calcium/ferrous fumarate/folic acid 04/15/2016 aurodex,aurodex antipyrine/benzocaine,antipy ear drops rine/benzocaine/glycerin REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 auroguard antipyrine/benzocaine REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 otic care antipyrine/benzocaine REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 arbinoxa carbinoxamine maleate REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 palgic carbinoxamine maleate REMOVE FROM FORMULARY Covered Non-Formulary cetirizine hcl CHANGE TIER Covered CHANGE TIER REMOVE FROM FORMULARY Covered Covered ADD UM: GENDER Non-Formulary Female BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 665 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/15/2016 palgic carbinoxamine maleate REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 arbinoxa carbinoxamine maleate ADD TO FORMULARY Non-Formulary Covered 04/15/2016 al-12 ammonium lactate REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 benzac ac benzoyl peroxide REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 benzac w wash benzoyl peroxide REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 kola-pectin ds bismuth subsalicylate REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 hecoria tacrolimus REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 hecoria tacrolimus REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 hecoria tacrolimus REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 prenaplus prenatal vits with calcium #74/ferrous fumarate/folic acid REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 LAYOLIS FE norethindrone-ethinyl estradiol/ferrous fumarate ADD TO FORMULARY Non-Formulary Covered 04/15/2016 pedi-dri nystatin REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 lidopin lidocaine hcl REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 medi-cortisone hydrocortisone acetate REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 parcaine proparacaine hcl REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 666 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/15/2016 ADVIL,ADVIL LIQUI-GELS ibuprofen REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 ADVIL MIGRAINE ibuprofen REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 motrin ib ibuprofen REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 CHILDREN'S FLONASE ALLERGY RLF fluticasone propionate REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 FLUVIRIN 2015- influenza virus vaccine 2016 trivalent 2015-2016 (4 yr & older) REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 FLUVIRIN 2015- influenza virus vaccine 2016 trivalnt 2015-2016 (4 yr & older)/pf REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 FLUZONE QUAD influenza virus vaccine 2015-2016 qvalsplit 2015-2016(6 mos and older) REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 FLUCELVAX 2015-2016 influenza vaccine trivalent 2015-2016(18 yr+)cell derived/pf REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 FLUZONE QUAD influenza virus vaccine PEDI 2015-2016 quadrival 2015-16 (6 mos35 mos)/pf REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 FLUZONE INTRADERM QUAD 2015-16 REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 FLUZONE QUAD influenza virus vaccine 2015-2016 quadrival split 2015-16(36 mos+)/pf REMOVE FROM FORMULARY Covered Non-Formulary influenza virus vaccine quadrivalent 2015-16(18yrs64yrs)/pf BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 667 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/15/2016 FLUARIX QUAD influenza virus vaccine 2015-2016 quadrival split 2015-16(36 mos+)/pf REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 FLUZONE QUAD influenza virus vaccine 2015-2016 quadrival split 2015-16(36 mos+)/pf REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 FLUBLOK 2015- influenza virus vaccine tv 2016 2015-2016(18 yrs & older)rcmb/pf REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 FLUMIST QUAD influenza vaccine 2015-2016 quadrivalent live 2015-2016 (2 yrs-49 yrs) REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 FLUZONE 2015- influenza virus vaccine 2016 trivalent 2015-16 (6 mos and older) REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 FLUZONE HIGH- influenza virus vaccine DOSE 2015-2016 trivalent split 2015-2016(65 yr+)/pf REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 AFLURIA 20152016 influenza virus vaccine trivalent 2015-2016 (5 yr & older) REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 FLULAVAL QUAD 20152016 influenza virus vaccine quadrival 2015-2016 (36 mos & older) REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 EZ FLU 20152016 (FLUCELVAX) influenza vaccine trivalent 2015-2016(18 yr+)cell derived/pf REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 EZ FLU 2015influenza virus vaccine 2016 (FLUVIRIN) trivalnt 2015-2016 (4 yr & older)/pf REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 AFLURIA 20152016 REMOVE FROM FORMULARY Covered Non-Formulary influenza virus vaccine trivalnt 2015-2016 (5 yr & older)/pf BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 668 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/15/2016 chlorhist chlorpheniramine maleate REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 aler-tab diphenhydramine hcl REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 levothyroxine sodium levothyroxine sodium CHANGE TIER 04/15/2016 myorisan isotretinoin REMOVE FROM FORMULARY 04/15/2016 zenatane isotretinoin ADD UM: AUTHORIZATION 04/15/2016 myorisan isotretinoin REMOVE FROM FORMULARY Covered 04/15/2016 myorisan isotretinoin REMOVE UM: AUTHORIZATION PA applies 04/15/2016 myorisan isotretinoin REMOVE FROM FORMULARY Covered 04/15/2016 myorisan isotretinoin REMOVE UM: AUTHORIZATION PA applies 04/15/2016 next choice levonorgestrel REMOVE FROM FORMULARY Covered Non-Formulary 04/15/2016 lidocream lidocaine REMOVE FROM FORMULARY Covered Non-Formulary 04/17/2016 rebetol,ribavirin,ri ribavirin basphere REMOVE UM: AUTHORIZATION PA applies 04/17/2016 PEGINTRON REMOVE UM: AUTHORIZATION PA applies 04/18/2016 copegus,ribavirin, ribavirin ribasphere,moder iba REMOVE UM: AUTHORIZATION PA applies 04/18/2016 PEGINTRON REDIPEN REMOVE UM: AUTHORIZATION PA applies peginterferon alfa-2b peginterferon alfa-2b Covered Covered Non-Formulary PA applies Non-Formulary Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 669 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/18/2016 PEGINTRON REDIPEN peginterferon alfa-2b REMOVE UM: AUTHORIZATION PA applies 04/18/2016 PEGINTRON REDIPEN peginterferon alfa-2b REMOVE UM: AUTHORIZATION PA applies 04/18/2016 PEGINTRON REDIPEN peginterferon alfa-2b REMOVE UM: AUTHORIZATION PA applies 04/18/2016 entocort budesonide ec,budesonide ec REMOVE UM: AUTHORIZATION PA applies 04/18/2016 PEGASYS PROCLICK peginterferon alfa-2a REMOVE UM: AUTHORIZATION PA applies 04/18/2016 PEGASYS PROCLICK peginterferon alfa-2a REMOVE UM: AUTHORIZATION PA applies 04/18/2016 PEGINTRON peginterferon alfa-2b REMOVE UM: AUTHORIZATION PA applies 04/18/2016 PEGINTRON peginterferon alfa-2b REMOVE UM: AUTHORIZATION PA applies 04/18/2016 raloxifene hcl raloxifene hcl 04/18/2016 bufferin aspirin/calcium carbonate/magnesium CHANGE UM: AGE 04/19/2016 retina,avita,tretinoin tretinoin CHANGE UM: AGE 10 to 29 yrs old 04/19/2016 retin-a,tretinoin tretinoin CHANGE UM: AGE 10 to 29 yrs old 04/19/2016 methergine,meth methylergonovine maleate ylergonovine maleate CHANGE UM: AGE At least 12 yrs old 04/19/2016 PROVENTIL HFA albuterol sulfate REMOVE FROM FORMULARY Not Covered Non-Formulary 04/19/2016 PROAIR HFA albuterol sulfate REMOVE FROM FORMULARY Not Covered Non-Formulary 04/29/2016 malathion,ovide malathion ADD UM: STEP CHANGE TIER Covered At least 40 yrs old 40 to 79 yrs old ST applies BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 670 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates May, 2016 Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2016 ciclopirox ciclopirox ADD TO FORMULARY Covered 05/01/2016 ciclopirox ciclopirox ADD UM: QUANTITY 6.6 / 28 days 05/01/2016 pain reliever acetaminophen CHANGE TIER Covered 05/01/2016 naproxen sodium naproxen sodium 05/01/2016 hydrocortisone hydrocortisone 05/01/2016 betamethasone dipropionate 05/01/2016 ADD TO FORMULARY Non-Formulary Covered CHANGE TIER Covered betamethasone dipropionate/propylene glycol ADD TO FORMULARY Covered betamethasone dipropionate betamethasone dipropionate ADD TO FORMULARY Covered 05/01/2016 betamethasone dipropionate betamethasone dipropionate/propylene glycol ADD TO FORMULARY Covered 05/01/2016 halobetasol propionate halobetasol propionate ADD TO FORMULARY Covered 05/01/2016 halobetasol propionate halobetasol propionate ADD TO FORMULARY Covered 05/01/2016 betamethasone dipropionate betamethasone dipropionate/propylene glycol ADD TO FORMULARY Covered 05/01/2016 naproxen naproxen CHANGE TIER Covered 05/01/2016 NEXIUM 24HR esomeprazole magnesium ADD TO FORMULARY Covered 05/01/2016 all day pain relief naproxen sodium ADD TO FORMULARY Non-Formulary Covered 05/01/2016 mediproxen naproxen sodium ADD TO FORMULARY Non-Formulary Covered 05/01/2016 naproxen sodium naproxen sodium ADD TO FORMULARY Non-Formulary Covered 05/01/2016 lc-4 ADD TO FORMULARY lidocaine Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 671 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name 05/01/2016 triple antibiotic neomycin sulfate/bacitracin zinc/polymyxin b 05/01/2016 moxeza,vigamox, moxifloxacin hcl avelox,avelox abc pack,moxifloxacin hcl Type of Change Previous Value New Value REMOVE FROM FORMULARY Covered Non-Formulary REMOVE UM: CUSTOM BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 672 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date 05/01/2016 Brand Name Generic Name child triaminic acetaminophen 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 nonaspirin,infants' pain-fever,nonaspirin,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. Type of Change Previous Value CHANGE UM: CUSTOM New Value Cumulative Max 4gm/day acetaminophen BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 673 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value tylenol meltaways,tylenol sore throat,feverall,edapap,children's pain and fever,pain & fever,children's pain & fever,children's pain-fever,qpap,q-pap extra strength,children' s qpap,acephen,ma pap,mapap infant,children's mapap,junior mapap,mapap arthritis pain,infants' mapap,nonaspirin extra strength,children' s pain reliever,pain reliever junior strength,8 hour pain relief,nonaspirin jr strength,infant's nonaspirin,infant's pain reliever,acetamin ophen extra strength,jr acetaminophen,f ever reducer-pain BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 674 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates 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 nonaspirin,pharbetol, acetaminophen pain relief,fever reducer,infant's acetaminophen,a cetadrink,genapa p,silapap,extende d pain relief,infants pain reliever,nonaspirin pain relief,acetaminop hen 8 hour,infants' nonaspirin,jr. str nonaspirin pain,8 hour pain reliever,jr. strength pain reliever,child nonaspirin,jr. str nonaspirin,nonaspirin 8 hour,infant painfever,children's acetaminophen,a spirin free,ofirmev,child' s accudial BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 675 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value acetaminophen,in fant pain relief,8 hour,children's easy-melts,meditabs,medi-tabs extra strength,children' s meditabs,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 feverpain,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 BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 676 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates 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 05/03/2016 DOVONEX calcipotriene REMOVE UM: AUTHORIZATION PA applies 05/03/2016 ALDARA imiquimod REMOVE UM: AUTHORIZATION PA applies 05/03/2016 ALDARA imiquimod REMOVE UM: QUANTITY 0.4 / day 05/03/2016 mefloquine hcl mefloquine hcl REMOVE UM: AUTHORIZATION PA applies 05/03/2016 CREON lipase/protease/amylase ADD UM: QUANTITY 42 / days 05/03/2016 NOVOLOG insulin aspart ADD UM: QUANTITY 0.667 / days 05/03/2016 trustex-ria condoms, latex, nonlubricated ADD UM: QUANTITY 36 / 30 days 05/03/2016 kimono maxx condoms, latex, nonlubricated ADD UM: QUANTITY 36 / 30 days 05/03/2016 kimono microthin condoms, latex, nonlubricated ADD UM: QUANTITY 36 / 30 days 05/03/2016 kimono condoms, latex, nonlubricated ADD UM: QUANTITY 36 / 30 days 05/03/2016 trustex condoms, latex, nonlubricated ADD UM: QUANTITY 36 / 30 days 05/03/2016 kimono microthin condoms, latex, lubricated ADD UM: QUANTITY 36 / 30 days BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 677 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/03/2016 trustex condom condoms, latex, lubricated ADD UM: QUANTITY 36 / 30 days 05/03/2016 trustex-ria condoms, latex, lubricated ADD UM: QUANTITY 36 / 30 days 05/03/2016 trustex-ria condoms, latex, lubricated ADD UM: QUANTITY 36 / 30 days 05/03/2016 condoms condoms, latex, lubricated ADD UM: QUANTITY 36 / 30 days 05/03/2016 kimono microthin condoms, latex, lubricated aqua lube ADD UM: QUANTITY 36 / 30 days 05/03/2016 fantasy condoms, latex, lubricated ADD UM: QUANTITY 36 / 30 days 05/03/2016 trustex latex condom condoms, latex, lubricated ADD UM: QUANTITY 36 / 30 days 05/03/2016 kimono textured condoms, latex, lubricated ADD UM: QUANTITY 36 / 30 days 05/03/2016 aimsco condoms, latex, lubricated ADD UM: QUANTITY 36 / 30 days 05/03/2016 durex avanti bare condoms, latex, lubricated ADD UM: QUANTITY 36 / 30 days 05/03/2016 fc2 female condom condoms, female ADD UM: QUANTITY 36 / 30 days 05/03/2016 CREON lipase/protease/amylase ADD UM: QUANTITY 28 / days 05/03/2016 CREON lipase/protease/amylase ADD UM: QUANTITY 168 / days 05/03/2016 ERYPED 200 erythromycin ethylsuccinate ADD UM: QUANTITY 6.7 / days 05/03/2016 ERYPED 200 erythromycin ethylsuccinate ADD UM: AGE Up to 12 yrs old 05/03/2016 CREON lipase/protease/amylase ADD UM: QUANTITY 336 / days 05/03/2016 MAPAP acetaminophen ADD UM: QUANTITY 124.923 / days 05/03/2016 MAPAP acetaminophen ADD UM: QUANTITY 124.923 / days 05/03/2016 APIDRA,APIDRA insulin glulisine SOLOSTAR 05/03/2016 nystop,nyamyc,p nystatin edidri,nystatin,myco statin REMOVE UM: AUTHORIZATION PA applies ADD UM: QUANTITY 2 / days BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 678 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name 05/03/2016 lindane lindane 05/04/2016 children's ibuprofen motrin,children's ibuprofen,ibuprof en,children's advil,child ibuprofen,childre n's profen ib,children's profenib,children' s mediprofen,motrin 05/04/2016 MAPAP 05/04/2016 Type of Change Previous Value New Value ADD UM: QUANTITY 2 / days CHANGE UM: QUANTITY 10 / days acetaminophen ADD UM: QUANTITY 30 / days CREON lipase/protease/amylase ADD UM: QUANTITY 90 / days 05/04/2016 hydrocodoneacetaminophen hydrocodone bitartrate/acetaminophen CHANGE UM: QUANTITY 60 / Day 180 / days 05/04/2016 hydrocodoneacetaminophen hydrocodone bitartrate/acetaminophen CHANGE UM: QUANTITY 60 / Day 180 / days 05/04/2016 vivelleestradiol dot,alora,minivell e,estradiol CHANGE UM: QUANTITY 0.0308 / day 0.308 / days 05/04/2016 vivelleestradiol dot,estraderm,alo ra,vivelle,minivell e,estradiol CHANGE UM: QUANTITY 0.0308 / day 0.308 / days 05/04/2016 TAMIFLU oseltamivir phosphate CHANGE UM: QUANTITY 10 / rx .112 / days 05/04/2016 TAMIFLU oseltamivir phosphate CHANGE UM: QUANTITY .112 / days 10 / rx 05/04/2016 TAMIFLU oseltamivir phosphate CHANGE UM: QUANTITY 0.222 / day 20 / rx 05/04/2016 AVONEX interferon beta-1a REMOVE UM: AUTHORIZATION PA applies 05/04/2016 nicotine patch nicotine ADD UM: QUANTITY 1 / days BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 679 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value Non-Formulary 05/04/2016 zenatane isotretinoin REMOVE FROM FORMULARY Covered 05/04/2016 zenatane isotretinoin REMOVE UM: AUTHORIZATION PA applies 05/04/2016 ABSORICA isotretinoin CHANGE UM: QUANTITY 1 / Day 2 / days 05/04/2016 myorisan isotretinoin CHANGE UM: QUANTITY 1 / Day 2 / days 05/04/2016 claravis,absorica, isotretinoin sotret,zenatane, myorisan 05/04/2016 lindane lindane 05/04/2016 zenatane isotretinoin REMOVE FROM FORMULARY Covered 05/04/2016 zenatane isotretinoin REMOVE UM: AUTHORIZATION PA applies 05/04/2016 amnesteem,clara isotretinoin vis,absorica,zena tane,myorisan,sot ret,accutane REMOVE UM: AUTHORIZATION 05/04/2016 zenatane isotretinoin REMOVE FROM FORMULARY Covered 05/04/2016 zenatane isotretinoin REMOVE UM: AUTHORIZATION PA applies 05/04/2016 claravis isotretinoin REMOVE UM: AUTHORIZATION PA applies 05/04/2016 zenatane isotretinoin REMOVE FROM FORMULARY Covered 05/04/2016 zenatane isotretinoin REMOVE UM: AUTHORIZATION PA applies 05/04/2016 claravis isotretinoin REMOVE UM: AUTHORIZATION PA applies REMOVE UM: AUTHORIZATION ADD UM: QUANTITY 2 / days Non-Formulary Non-Formulary Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 680 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/04/2016 ABSORICA isotretinoin CHANGE UM: QUANTITY 1 / Day 2 / days 05/04/2016 amnesteem isotretinoin CHANGE UM: QUANTITY 1 / Day 2 / days 05/04/2016 lice killing,lice piperonyl treatment,rid,licid butoxide/pyrethrins e,lice pyrinyl shampoo,a-200 lice killing 05/04/2016 rid piperonyl butoxide/pyrethrins 05/04/2016 ZOFRAN ODT 05/04/2016 ADD UM: QUANTITY 2 / days REMOVE FROM FORMULARY Covered Non-Formulary ondansetron CHANGE UM: QUANTITY 0.6 / day 3 / days ZOFRAN ODT ondansetron CHANGE UM: QUANTITY 0.8 / day 3 / days 05/04/2016 ZOFRAN ondansetron hcl CHANGE UM: QUANTITY 0.6 / day 3 / days 05/04/2016 ZOFRAN ondansetron hcl CHANGE UM: QUANTITY 0.8 / day 3 / days 05/04/2016 mepron,atovaquo atovaquone ne REMOVE UM: AUTHORIZATION PA applies 05/04/2016 MEPRON REMOVE FROM FORMULARY Covered 05/04/2016 namenda,namen memantine hcl da xr,memantine hcl REMOVE UM: AUTHORIZATION 05/04/2016 child pain relacetaminophen fever reducer,children's fever reducer,feverall,a cetaminophen,ac ephen,children's non-aspirin,fever reducer,children's fever reducing CHANGE UM: QUANTITY 33 / days 05/04/2016 acetaminophen, mapap CHANGE UM: QUANTITY 125 / days atovaquone acetaminophen Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 681 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 30 / Day 125 / days 05/04/2016 acetaminophen,c acetaminophen hildren's acetaminophen CHANGE UM: QUANTITY 05/04/2016 children's pain acetaminophen and fever,mapap,acet aminophen,nonaspirin,children's nonaspirin,children's acetaminophen,a pra,children's pain relief,st. joseph CHANGE UM: QUANTITY 125 / days 05/04/2016 hycet,hydrocodon hydrocodone e-acetaminophen bitartrate/acetaminophen CHANGE UM: QUANTITY 184 / days 05/04/2016 hydrocodoneacetaminophen hydrocodone bitartrate/acetaminophen CHANGE UM: QUANTITY 60 / Day 184 / days 05/04/2016 hydrocodoneacetaminophen hydrocodone bitartrate/acetaminophen CHANGE UM: QUANTITY 184 / days 60 / days 05/04/2016 hycet,hydrocodon hydrocodone e-acetaminophen bitartrate/acetaminophen CHANGE UM: QUANTITY 184 / days 60 / days 05/04/2016 acetaminophen,c acetaminophen hildren's acetaminophen CHANGE UM: QUANTITY 125 / days 30 / days 05/04/2016 acetaminophen, mapap CHANGE UM: QUANTITY 125 / days 30 / days acetaminophen BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 682 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/04/2016 children's pain acetaminophen and fever,mapap,acet aminophen,nonaspirin,children's nonaspirin,children's acetaminophen,a pra,children's pain relief,st. joseph CHANGE UM: QUANTITY 125 / days 30 / days 05/04/2016 depomedroxyprogesterone provera,medroxy acetate progesterone acetate CHANGE UM: QUANTITY 1 / 270 Days 1 / 90 days 05/04/2016 depomedroxyprogesterone provera,medroxy acetate progesterone acetate CHANGE UM: QUANTITY 1 / 270 Days 1 / 90 days 05/05/2016 mapap,tylophen, acetaminophen pain reliever,nonaspirin extra strength,pain relief CHANGE UM: QUANTITY 05/05/2016 children's pain acetaminophen and fever,mapap,acet aminophen,nonaspirin,children's nonaspirin,children's acetaminophen,a pra,children's pain relief,st. joseph CHANGE UM: QUANTITY 8 / days 30 / days 125 / days BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 683 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/05/2016 acetaminophen,c acetaminophen hildren's acetaminophen CHANGE UM: QUANTITY 30 / days 125 / days 05/05/2016 acetaminophen, mapap acetaminophen CHANGE UM: QUANTITY 30 / days 125 / days 05/05/2016 acetaminophencodeine acetaminophen with codeine CHANGE UM: QUANTITY phosphate 90 / Day 166 / days 05/05/2016 acetaminophencodeine acetaminophen with codeine CHANGE UM: QUANTITY phosphate 90 / Day 166 / days 05/05/2016 APIDRA insulin glulisine REMOVE UM: QUANTITY 2 / Day 05/05/2016 triple antibiotic neomycin sulfate/bacitracin zinc/polymyxin b ADD TO FORMULARY Non-Formulary Covered 05/05/2016 bupropion hcl sr,bupropion hcl er bupropion hcl REMOVE FROM FORMULARY Covered Non-Formulary 05/05/2016 sulfamethoxazole sulfamethoxazole/trimethopr -trimethoprim im REMOVE FROM FORMULARY Covered Non-Formulary 05/05/2016 sulfamethoxazole sulfamethoxazole/trimethopr -trimethoprim im ADD TO FORMULARY Non-Formulary Covered 05/05/2016 renvela,sevelame sevelamer carbonate r carbonate REMOVE UM: AUTHORIZATION PA applies 05/05/2016 NOVOLOG MIX insulin aspart protamine 70-30 human/insulin aspart FLEXPEN,NOVO LOG MIX 70-30 REMOVE UM: AUTHORIZATION PA applies 05/05/2016 bupropion hcl sr,bupropion hcl er ADD TO FORMULARY Non-Formulary Covered 05/05/2016 FLUMIST QUAD influenza vaccine 2015-2016 quadrivalent live 2015-2016 (2 yrs-49 yrs) ADD TO FORMULARY Non-Formulary Covered bupropion hcl BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 684 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/05/2016 FLUCELVAX 2015-2016 influenza vaccine trivalent 2015-2016(18 yr+)cell derived/pf ADD TO FORMULARY Non-Formulary Covered 05/05/2016 EZ FLU 20152016 (FLUCELVAX) influenza vaccine trivalent 2015-2016(18 yr+)cell derived/pf ADD TO FORMULARY Non-Formulary Covered 05/05/2016 FLUZONE QUAD influenza virus vaccine PEDI 2015-2016 quadrival 2015-16 (6 mos35 mos)/pf ADD TO FORMULARY Non-Formulary Covered 05/05/2016 FLULAVAL QUAD 20152016 ADD TO FORMULARY Non-Formulary Covered 05/05/2016 FLUZONE QUAD influenza virus vaccine 2015-2016 quadrival split 2015-16(36 mos+)/pf ADD TO FORMULARY Non-Formulary Covered 05/05/2016 FLUZONE QUAD influenza virus vaccine 2015-2016 quadrival split 2015-16(36 mos+)/pf ADD TO FORMULARY Non-Formulary Covered 05/05/2016 FLUARIX QUAD influenza virus vaccine 2015-2016 quadrival split 2015-16(36 mos+)/pf ADD TO FORMULARY Non-Formulary Covered 05/05/2016 FLUZONE INTRADERM QUAD 2015-16 ADD TO FORMULARY Non-Formulary Covered 05/05/2016 FLUZONE QUAD influenza virus vaccine 2015-2016 qvalsplit 2015-2016(6 mos and older) ADD TO FORMULARY Non-Formulary Covered 05/05/2016 FLUBLOK 2015- influenza virus vaccine tv 2016 2015-2016(18 yrs & older)rcmb/pf ADD TO FORMULARY Non-Formulary Covered 05/05/2016 AFLURIA 20152016 ADD TO FORMULARY Non-Formulary Covered influenza virus vaccine quadrival 2015-2016 (36 mos & older) influenza virus vaccine quadrivalent 2015-16(18yrs64yrs)/pf influenza virus vaccine trivalnt 2015-2016 (5 yr & older)/pf BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 685 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/05/2016 EZ FLU 2015influenza virus vaccine 2016 (FLUVIRIN) trivalnt 2015-2016 (4 yr & older)/pf ADD TO FORMULARY Non-Formulary Covered 05/05/2016 FLUVIRIN 2015- influenza virus vaccine 2016 trivalnt 2015-2016 (4 yr & older)/pf ADD TO FORMULARY Non-Formulary Covered 05/05/2016 FLUZONE HIGH- influenza virus vaccine DOSE 2015-2016 trivalent split 2015-2016(65 yr+)/pf ADD TO FORMULARY Non-Formulary Covered 05/05/2016 AFLURIA 20152016 influenza virus vaccine trivalent 2015-2016 (5 yr & older) ADD TO FORMULARY Non-Formulary Covered 05/05/2016 FLUVIRIN 2015- influenza virus vaccine 2016 trivalent 2015-2016 (4 yr & older) ADD TO FORMULARY Non-Formulary Covered 05/05/2016 FLUZONE 2015- influenza virus vaccine 2016 trivalent 2015-16 (6 mos and older) ADD TO FORMULARY Non-Formulary Covered 05/05/2016 sandostatin,octre octreotide acetate otide acetate REMOVE UM: AUTHORIZATION 05/05/2016 SENSIPAR REMOVE UM: AUTHORIZATION 05/05/2016 soriatane,acitretin acitretin 05/05/2016 durex avanti bare condoms, latex, lubricated REMOVE FROM FORMULARY Covered Non-Formulary 05/05/2016 lc-4 lidocaine REMOVE FROM FORMULARY Covered Non-Formulary 05/06/2016 glucosource lancing device,lancets REMOVE FROM FORMULARY Covered Non-Formulary cinacalcet hcl REMOVE UM: AUTHORIZATION BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 686 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change REMOVE UM: STEP Previous Value New Value Non-Formulary Covered 05/09/2016 HUMULIN N,NOVOLIN N,HUMULIN N KWIKPEN insulin nph human isophane 05/11/2016 kionex sodium polystyrene sulfonate ADD TO FORMULARY 05/11/2016 sodium polystyrene sulfonate sodium polystyrene sulfonate ADD TO FORMULARY Covered 05/11/2016 calcium,calcium carbonate calcium carbonate ADD TO FORMULARY Covered 05/11/2016 calcium calcium carbonate ADD TO FORMULARY Non-Formulary Covered 05/11/2016 high potency calcium calcium carbonate ADD TO FORMULARY Non-Formulary Covered 05/11/2016 calcium gluconate calcium gluconate ADD TO FORMULARY Non-Formulary Covered 05/11/2016 FOLGARD OS calcium carb/mag oxide/vitamin d3/vit b12/fa/vit b6/boron ADD TO FORMULARY Non-Formulary Covered 05/11/2016 tl g-fol os calcium carb/mag oxide/vitamin d3/vit b12/fa/vit b6/boron ADD TO FORMULARY Non-Formulary Covered 05/20/2016 revatio,sildenafil sildenafil citrate ADD TO FORMULARY 05/20/2016 REVATIO sildenafil citrate REMOVE FROM FORMULARY Covered Non-Formulary 05/24/2016 PROSIGHT vit a/c/e acetate/zinc oxide/sodium selenate/cupric oxide ADD TO FORMULARY Non-Formulary Covered 05/24/2016 kelp-lecithin-vit b- lecithin/pyridoxine/kelp 6 ADD TO FORMULARY Non-Formulary Covered Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 687 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 kelp-lecithin-vit b- lecithin/pyridoxine/kelp 6 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 kelp-lecithin-b-6- lecithin/pyridoxine/kelp vinegar ADD TO FORMULARY Non-Formulary Covered 05/24/2016 kelp-lecithin-vit b- lecithin/pyridoxine/kelp 6 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 l-methyl-mc nac acetylcysteine/mecobalamin /levomefolate calcium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 metafolbic plus acetylcysteine/mecobalamin /levomefolate calcium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 MG-PLUSPROTEIN magnesium oxide/magnesium amino acid chelate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 MEN'S POTENT calcium/vitamin e/folic FORMULA acid/pyridoxine/herbal drugs ADD TO FORMULARY Non-Formulary Covered 05/24/2016 kelp-lecithin-vit b- lecithin/pyridoxine/kelp 6 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 hydralazine hcl hydralazine hcl ADD TO FORMULARY 05/24/2016 hydralazine hcl hydralazine hcl ADD TO FORMULARY Non-Formulary Covered 05/24/2016 hydralazine hcl hydralazine hcl CHANGE UM: QUANTITY 3 / Day 3 / Day 05/24/2016 prostamen vitamin e acetate/copper/selenium/zn ox/pyg afri/saw palmetto ADD TO FORMULARY Non-Formulary Covered 05/24/2016 SPS sodium polystyrene sulfonate/sorbitol solution ADD TO FORMULARY Non-Formulary Covered 05/24/2016 sodium polystyrene sulfonate sodium polystyrene sulfonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 sodium polystyrene sulfonate sodium polystyrene sulfonate ADD TO FORMULARY Non-Formulary Covered Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 688 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 SPS sodium polystyrene sulfonate/sorbitol solution ADD TO FORMULARY Non-Formulary Covered 05/24/2016 KIONEX sodium polystyrene sulfonate/sorbitol solution ADD TO FORMULARY Non-Formulary Covered 05/24/2016 sodium polystyrene sulfonate sodium polystyrene sulfonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 sodium polystyrene sulfonate sodium polystyrene sulfonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 KAYEXALATE sodium polystyrene sulfonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium amino acid chelate calcium amino acid chelate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 super calcium calcium carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium carbonate calcium carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CAL-MINT calcium carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium carbonate calcium carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium citrate calcium citrate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium citrate calcium citrate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CALCIONATE calcium glubionate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium gluconate calcium gluconate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium gluconate calcium gluconate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium lactate calcium lactate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium lactate calcium lactate ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 689 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 coral calcium calcium carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium gluconate calcium gluconate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium phosphate calcium phosphate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 BIOCAL calcium carbonate/vit d3/magnesium oxide/folic acid/vit k ADD TO FORMULARY Non-Formulary Covered 05/24/2016 PRO-CAL calcium phosphat/magnesium hydroxide/vit c/vit d3/phosphorus ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CALCI-MAX calcium/fa/b complex/d3/e/citrus bioflavonoids/soy extract ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium with boron calcium carbonate/boron gluconate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 SUPER CALMAG calcium carbonate/magnesium oxide ADD TO FORMULARY Non-Formulary Covered 05/24/2016 oyster shell calciummagnesium calcium carbonate/magnesium oxide ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CAL-MAG calcium carbonate/magnesium oxide, carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 LOCALNESIUM calcium carbonate and citrate/magnesium citrate, glycinate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CALMAG THINS calcium carbonate and citrate/magnesium oxide ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calciummagnesium-zinc ADD TO FORMULARY Non-Formulary Covered calcium/magnesium/zinc BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 690 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name calcium/magnesium/zinc Type of Change Previous Value New Value ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calciummagnesium-zinc 05/24/2016 calciumcalcium carbonate/vit magnesium-zinc- d3/magnesium ox & vit d stearate/zinc sulf ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calciummagnesium-zinc calcium/magnesium/zinc ADD TO FORMULARY Non-Formulary Covered 05/24/2016 soft chews calcium calcium carbonate/cholecalciferol (vit d3)/phytonadione ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium soft chew calcium carbonate/cholecalciferol (vit d3)/phytonadione ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium calcium carbonate/cholecalciferol (vit d3)/phytonadione ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium soft chew calcium carbonate/cholecalciferol (vit d3)/phytonadione ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium + vitamin calcium d&k carbonate/cholecalciferol (vit d3)/phytonadione ADD TO FORMULARY Non-Formulary Covered 05/24/2016 viactiv calcium carbonate/cholecalciferol (vit d3)/phytonadione ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium-vit d3-vit calcium k carbonate/cholecalciferol (vit d3)/phytonadione ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CITRACAL ADD TO FORMULARY Non-Formulary Covered calcium carbonate/cholecalciferol (vit d3)/phytonadione BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 691 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 calcium 500 + vit calcium d,calcium + d carbonate/cholecalciferol (vit d3)/phytonadione ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium soft chew calcium carbonate/cholecalciferol (vit d3)/phytonadione ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium plus vitamin d calcium carbonate/vit d3/mag ox/zinc/copper/manganese/ boron ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium 600+minerals calcium carbonate/cholecalciferol (vit d3)/minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium 600+minerals calcium carbonate/cholecalciferol (vit d3)/minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium 600+d calcium plus carbonate/cholecalciferol (vit minerals,calcium d3)/minerals 600+d & minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CALTRATE 600+D PLUS calcium carbonate/d3/mag #11/zinc/cupric su/manganese/boron ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CALCIUM 600D3 PLUS calcium carbonate/vit d3/mag ox/zinc/copper/manganese/ boron ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium 600+d+minerals, calcium 600 + vit d calcium carbonate/vit d3/mag ox/zinc/copper/manganese/ boron ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 692 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 calcium 600-vit calcium d3carbonate/cholecalciferol (vit mineral,calcium d3)/minerals +d & minerals,calcium 600+d & minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CALTRATE 600+D3 PLUS MINERALS,CAL TRATE 600+D PLUS calcium carb/vit d3/mag ox/zinc/copper/manganese/ mg borate,calcium carbonate/vit d3/mag ox/zinc/copper/manganese/ boron ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium 600+d calcium carbonate/vit plus,calcium d3/mag 600+d3+minerals ox/zinc/copper/manganese/ boron ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CITRACAL D + calcium carbonate and HEART HEALTH citrate/vitamin d3/phytosterol ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CORAL CALCIUM calcium/magnesium oxide/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium 500 calcium carbonate,citrate/magnesiu m oxide,aspartate/vit d3 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium magnesium + d calcium carbonate/magnesium oxide/cholecalciferol (vit d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 coral calcium calcium carbonate/cholecalciferol/ma gnesium amino ac chelate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 coral calcium calcium carbonate/magnesium oxide/cholecalciferol (vit d3) ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 693 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 CORAL CALCIUM calcium/magnesium oxide/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 coral calcium calcium carbonate/magnesium/chole calciferol (vit d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 LOCALNESIUM- calcium C carbonate/magnesium oxide/ascorbic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ADVANCED CALCIUM calcium citrate/minerals/vitamin d3/vit k2/silicon dioxide ADD TO FORMULARY Non-Formulary Covered 05/24/2016 bone density calcium + d calcium carbonate/vitamin d3/arginine/inositol/silicon ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CITRACAL + calcium carb,citrate/vitamin BONE DENSITY d3/mineral comb no.34/genistein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 FEM-CAL CITRATE ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CITRACAL-VIT D calcium + MAGNESIUM cit/magnesium/d3/zinc ox/copper gluc/manganese/boron ADD TO FORMULARY Non-Formulary Covered 05/24/2016 cal mag zinc + calcium carbonate/vitamin d3,cal mag zinc + d3/magnesium oxide/zinc d oxide ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium calcium carbonate/cholecalciferol (vit d3)/minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calciummagnesium calcium/magnesium ADD TO FORMULARY Non-Formulary Covered calcium citrate/magnesium ox/vit d2/manganese/boron/silica BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 694 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 soy formula calcium carbonate/cholecalciferol (vit d3)/soybean ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium in premium chocolate calcium carbonate/magnesium oxide/cholecalciferol (vit d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium citrate plus calcium cit/magnesium/d3/zinc ox/copper gluc/manganese gluc ADD TO FORMULARY Non-Formulary Covered 05/24/2016 BONE ESSENTIALS calcium hydroxyapatite/vitamin d3/vitamin c/vit k2/minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium 600 plus calcium soy,calcium 600 carbonate/ergocalciferol (vit with soy d2)/soybean ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium,chewable calcium calcium carbonate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium 600-vit d3 calcium carbonate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium 600-vit calcium d3,calcium 600 + carbonate/cholecalciferol vit d,calcium 600 (vitamin d3) with vitamin d ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium with calcium vitamin d,calcium carbonate/cholecalciferol 600-vit d3 (vitamin d3) ADD TO FORMULARY 05/24/2016 calcium with calcium vitamin d,calcium carbonate/cholecalciferol 600-vit (vitamin d3) d3,calcium 600 + vit d ADD TO FORMULARY Covered Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 695 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 CALCET PETITES calcium carbonate, calcium lactate-cholecalciferol (vit d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 PARVA-CAL 250 calcium carbonate,calcium gluconate/ergocalciferol (vit d2) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 PARVA-CAL 500 calcium carbonate,calcium gluconate/ergocalciferol (vit d2) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium 600 + vit calcium d carbonate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 liquid calcium 600-vit d3 calcium carbonate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 liquid calcium + vitamin d calcium carbonate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium calcium carbonate/vitamin carbonate/cholecalciferol d3 (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 OYSCO D calcium carbonate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 oyster shell + d calcium carbonate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 oyster shell calcium w-vit d calcium carbonate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 oyster shell calcium w-vit d calcium carbonate/ergocalciferol (vitamin d2) ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 696 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 calcium 500-vit calcium d3,calcium 500 + carbonate/cholecalciferol vit d (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 oystercal-d calcium carbonate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 oyster shell calcium calcium-vitamin d carbonate/cholecalciferol (vitamin d3) ADD TO FORMULARY 05/24/2016 oyster shell calcium-vitamin d,oyster shell calcium calcium carbonate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium 500-vit d3 calcium carbonate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium 500-vit d3 calcium carbonate/cholecalciferol (vitamin d3) ADD TO FORMULARY 05/24/2016 calcium 500-vit d3 calcium carbonate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium 500 + vitamin d calcium carbonate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium 500 + vitamin d calcium carbonate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 os-cal 500-vit d3,os-cal 500+d calcium carbonate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered Covered Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 697 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 calcium 500-vit d3 calcium carbonate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 hi-cal calcium carbonate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium 500-vit d3 calcium carbonate/cholecalciferol (vitamin d3) ADD TO FORMULARY 05/24/2016 calcium 500 + calcium d,calcium 500-vit carbonate/cholecalciferol d3,calcium 500 + (vitamin d3) vit d ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium 500 + vit calcium d,calcium 500-vit carbonate/cholecalciferol d3,oyster shell (vitamin d3) calcium w-vit d,oyster shell calcium-vit d3 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 oysco 500-vit d3 calcium carbonate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 oyster shell calcium-vit d3 calcium carbonate/cholecalciferol (vitamin d3) ADD TO FORMULARY 05/24/2016 oyster shell calcium-vit d3,oyster shell calcium w-vit d calcium carbonate/cholecalciferol (vitamin d3),calcium carbonate/ergocalciferol (vitamin d2) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium 600 + vit calcium d carbonate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered Covered Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 698 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 calcium 600-vit d3 calcium carbonate/cholecalciferol (vitamin d3) ADD TO FORMULARY Covered 05/24/2016 calcium 600-vit calcium d3,calcium 600 + carbonate/cholecalciferol vit d,super (vitamin d3) calcium 600-vit d3,calcium with vitamin d ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium 600-vit calcium d3,calcium 600 + carbonate/cholecalciferol vit d (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium 600-vit d3 calcium carbonate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CALTRATE 600 +D calcium carbonate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium 600 + vit calcium d carbonate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium + d calcium carbonate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium 600 + vitamin d,liquid calcium 600-vit d3 calcium carbonate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium + vit calcium d3,calcium 600 + carbonate/cholecalciferol vitamin d (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 liquid calcium-vit calcium d carbonate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 699 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 calcium 500-vit d3 calcium carbonate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 OS-CAL 500-VIT calcium D3 carbonate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CALTRATE 600 PLUS D3 calcium carbonate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium 600-vit d3 calcium carbonate/cholecalciferol (vitamin d3) ADD TO FORMULARY 05/24/2016 calcium 600-vit d3 calcium carbonate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 OSTEOPORETICAL calcium carbonate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium 1000 + d3 calcium carbonate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium 500 + vit calcium d carbonate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium 500 + vit calcium d carbonate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CAL-QUICK calcium carbonate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium citratevitamin d calcium citrate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 700 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value Non-Formulary Covered 05/24/2016 citrus calciumvitamin d calcium citrate/cholecalciferol (vitamin d3) ADD TO FORMULARY 05/24/2016 calcium citrate +vit d3 calcium citrate/cholecalciferol (vitamin d3) ADD TO FORMULARY 05/24/2016 calcium citrate +vit d3 calcium citrate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CITRACALVITAMIN D calcium citrate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium citratecalcium vitamin d,calcium citrate/cholecalciferol citrate-vitamin d3 (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 citracal-vitamin d calcium citrate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 citrus calcium + d calcium citrate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium citrate vitamin d3,calcium citrate-vitamin d3,calcium citrate-vitamin d ADD TO FORMULARY calcium citrate/cholecalciferol (vitamin d3) Covered Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 701 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 calcium citrate - calcium vitamin d,calcium citrate/cholecalciferol citrate-vit (vitamin d3) d,calcium citratevitamin d3,calcium citrate - vitamin d3,calcium citrate-vitamin d,calcium citrate+d,calcium citrate- vitamin d ADD TO FORMULARY Non-Formulary Covered 05/24/2016 citracal + d,citracal + d maximum calcium citrate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcitrate + vit d calcium citrate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium citrate - calcium vitamin d,calcium citrate/cholecalciferol citrate-vitamin d3 (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium citrate vitamin d calcium citrate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium citrate plus calcium citrate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 UPCAL D calcium citrate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 UPCAL D calcium citrate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 702 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 calcium citrate malate with d calcium citrate malate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium + vitamin calcium phosphate, d3 tribasic/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CALTRATE GUMMY BITES calcium phosphate, tribasic/cholecalciferol (vitamin d3) ADD TO FORMULARY 05/24/2016 CALTRATE GUMMY BITES calcium phosphate, tribasic/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 risacal-d calcium phosphate, dibasic/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calvite p&d calcium phosphate, dibasic/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 children's calcium calcium phosphate gummies tribasic/ergocalciferol (vitamin d2) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CITRACAL + D3 calcium phosphate, tribasic/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium calcium phosphate, tribasic/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CITRACAL + D calcium carbonate and citrate/cholecalciferol (vit d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium + vitamin calcium carbonate and d3,calcium + d3 citrate/cholecalciferol (vit d3) ADD TO FORMULARY Non-Formulary Covered Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 703 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 THERACAL calcium cit/vit d3/vit k/mag ox/strontium cit/sodium borate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 THERACAL calcium cit/vit d3/vit k/mag ox/strontium cit/sodium borate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 PROSTEON calcium cit/vit d3/vit k/mag ox/strontium cit/sodium borate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 THERACAL calcium cit/vit d3/vit k/mag ox/strontium cit/sodium borate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CALCET calcium citrate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium adult calcium phosphate, tribasic/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 FLINTSTONES BONE SUPPORT calcium phosphate, tribasic/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium citratevitamin d calcium citrate/ergocalciferol (vitamin d2) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium + vit d calcium carbonate/cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 PERFECT IRON iron,carbonyl ADD TO FORMULARY Non-Formulary Covered 05/24/2016 FEOSOL iron,carbonyl ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ICAR iron,carbonyl ADD TO FORMULARY Non-Formulary Covered 05/24/2016 iron chews iron,carbonyl ADD TO FORMULARY Non-Formulary Covered 05/24/2016 wee care iron,carbonyl ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 704 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 ICAR iron,carbonyl ADD TO FORMULARY Non-Formulary Covered 05/24/2016 iron ferrous sulfate, dried ADD TO FORMULARY Non-Formulary Covered 05/24/2016 slow release iron ferrous sulfate, dried ADD TO FORMULARY Non-Formulary Covered 05/24/2016 SLOW RELEASE ferrous sulfate, dried IRON ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ferrous sulfate ferrous sulfate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ferrous sulfate ferrous sulfate ADD UM: AGE 05/24/2016 ferrous sulfate ferrous sulfate CHANGE UM: AGE 05/24/2016 FEROSUL ferrous sulfate ADD TO FORMULARY 05/24/2016 FEROSUL ferrous sulfate ADD TO FORMULARY 05/24/2016 FEROSUL ferrous sulfate ADD UM: AGE 05/24/2016 FEROSUL ferrous sulfate CHANGE UM: AGE 0 to 12 yrs old Up to 12 yrs old 05/24/2016 iron ferrous sulfate, dried ADD TO FORMULARY Non-Formulary Covered 05/24/2016 slow release iron ferrous sulfate, dried ADD TO FORMULARY Non-Formulary Covered 05/24/2016 iron ferrous gluconate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 FERATE ferrous gluconate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 iron ferrous gluconate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ferrous gluconate ferrous gluconate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ferrous gluconate ferrous gluconate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ferrous gluconate ferrous gluconate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 FERRETTS ferrous fumarate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ferrous fumarate ferrous fumarate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 PROFERRIN iron heme polypeptide ADD TO FORMULARY Non-Formulary Covered 05/24/2016 FERRETTS IPS iron succinyl-protein complex ADD TO FORMULARY Non-Formulary Covered Up to 12 yrs old 0 to 12 yrs old Up to 12 yrs old Covered Non-Formulary Covered Up to 12 yrs old BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 705 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 VENOFER iron sucrose complex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 VENOFER iron sucrose complex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 VENOFER iron sucrose complex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 NOVAFERRUM 50 iron polysaccharide complex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 NU-IRON 150 iron polysaccharide complex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 PRO FE iron polysaccharide complex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ezfe 200 iron polysaccharide complex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 IRONUP iron polysaccharide complex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 NOVAFERRUM iron polysaccharide complex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 INJECTAFER ferric carboxymaltose ADD TO FORMULARY Non-Formulary Covered 05/24/2016 FERAHEME ferumoxytol ADD TO FORMULARY Non-Formulary Covered 05/24/2016 sod ferric gluconate complex sodium ferric gluconate complex in sucrose ADD TO FORMULARY Non-Formulary Covered 05/24/2016 FERRLECIT sodium ferric gluconate complex in sucrose ADD TO FORMULARY Non-Formulary Covered 05/24/2016 TANDEM DUAL ACTION ferrous fumarate/iron polysaccharide complex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 NOVAFERRUM 125 iron polysaccharide complex/cholecalciferol (vit d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ICAR-C PLUS iron,carbonyl/ascorbic acid/cyanocobalamin/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ferrous gluconate ferrous gluconate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 FERRETTS ADD TO FORMULARY Non-Formulary Covered iron,carbonyl BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 706 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 APETIGENPLUS ferrous gluconate/lysine hcl/vit e/vit b cplex with c/zinc ADD TO FORMULARY Non-Formulary Covered 05/24/2016 PARVLEX ferrous fumarate/folic acid/vitamin b comp and c/minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 SIDEROL iron/liver extract/vitamin b comp and c/minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 central-vite multivitamin with minerals,multivitamin with iron,hematinic ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CORVITE folic acid/multivitamin,ther and minerals/lycopene/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 corvita folic acid/multivitamin,ther and minerals/lycopene/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 HEMATOGEN ferrous fumarate/ascorbic acid/cyanocobalamin/stoma ch conc ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CORVITE FE iron,carbonyl/methyltetrahyd rofolate gluc,fa/mv, min no.40 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CORVITE 150 iron,carbonyl/methyltetrahyd rofolate gluc,fa/mv, min no.41 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 I.L.X. B-12 iron/vitamin b complex/cyanocobalamin/liv er extract ADD TO FORMULARY Non-Formulary Covered 05/24/2016 VITRON-C iron,carbonyl/ascorbic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 fe c iron,carbonyl/ascorbic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 iron 100-vitamin c iron,carbonyl/ascorbic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ICAR-C ADD TO FORMULARY Non-Formulary Covered iron,carbonyl/ascorbic acid BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 707 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 FEOSOL iron polysaccharide complex/iron heme polypeptide ADD TO FORMULARY Non-Formulary Covered 05/24/2016 duofer iron polysaccharide complex/iron heme polypeptide ADD TO FORMULARY Non-Formulary Covered 05/24/2016 folitab 500 ferrous sulfate/ascorbic acid/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 hematogen fa ferrous fumarate/ascorbic acid/cyanocobalamin/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 trigels-f forte ferrous fumarate/ascorbic acid/cyanocobalamin/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 hematogen forte ferrous fumarate/ascorbic acid/cyanocobalamin/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ferrogels forte ferrous fumarate/ascorbic acid/cyanocobalamin/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 INTEGRA iron fumarate/iron polysac complex/vitamin c/niacinamide ADD TO FORMULARY Non-Formulary Covered 05/24/2016 FUSION iron fumarate-iron polysaccharide combo no.1/vit c/l. casei ADD TO FORMULARY Non-Formulary Covered 05/24/2016 NEPHRON FA ferrous fumarate/docusate/folic acid/vitamin b comp and c ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ferocon ferrous fumarate/ascorbic acid/b12-if/folic acid ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 708 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value Non-Formulary Covered 05/24/2016 tl icon ferrous fumarate/ascorbic acid/b12-if/folic acid ADD TO FORMULARY 05/24/2016 tricon ferrous fumarate/ascorbic acid/b12-if/folic acid ADD TO FORMULARY 05/24/2016 tricon ferrous fumarate/ascorbic acid/b12-if/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 taron forte iron bisgly,pscmplx/ascorbate calc/b12/folic acid/calc-threo ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ferrex 150 plus iron asp gly,ps cmplx/ascorb calcium/ca-thr/succinic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 MAXARON FORTE iron glycin,sulfumu/vitc/b12/methyltetrahy drofolate calcium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ABATRON iron ps/fa/vitamin b complex no.16/mag sulfate/zinc sulfate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 HEMATRON ferric ammonium citrate/lysine/vitamin b complex/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 multigen iron aspgly/ascorb.cal/vit b12/calcium thr/succ.acid/stomach ADD TO FORMULARY Non-Formulary Covered 05/24/2016 mv-iron-asc-b12- iron aspgly/ascorb.cal/vit thre-suc-stom b12/calcium thr/succ.acid/stomach ADD TO FORMULARY Non-Formulary Covered 05/24/2016 multigen folic iron asp gly/ascorb.cal/vit b12/fa/ca-threonte/succinic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 IRON 21/7 iron bis-glycinate chelate/fa/vit c/b12/cathr/succinic acid ADD TO FORMULARY Non-Formulary Covered Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 709 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 folivane-plus iron fumarate,polysac cplex/folic acid/vit b comp with c #9 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 INTEGRA PLUS iron fumarate,polysac cplex/folic acid/vit b comp with c #9 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CORVITE 150 iron,carbonyl/folic acid/vit c/pyridoxine hcl/vit b12/zinc ADD TO FORMULARY Non-Formulary Covered 05/24/2016 corvita 150 iron,carbonyl/folic acid/vit c/pyridoxine hcl/vit b12/zinc ADD TO FORMULARY Non-Formulary Covered 05/24/2016 FERIVA FA iron bisgly,aspart,fumarate/fa#1/ vit c/b12/biotin/copper/dss ADD TO FORMULARY Non-Formulary Covered 05/24/2016 mv-iron fum-asp- iron asc-b12-fa-suc fum,ag/ascorb.calcium/b12/f olic acid/calcium/succ.acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 multigen plus iron fum,ag/ascorb.calcium/b12/f olic acid/calcium/succ.acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ferrex 150 forte plus iron asp,gly,ps/ascorb.calcium/b 12/folic/calcium/succ.acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 iron ag-ps-ascb12-fa-thre-suc iron asp,gly,ps/ascorb.calcium/b 12/folic/calcium/succ.acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 IROSPAN iron bisgl,ps cmplx/folic acid/vit b,c no.12/succinic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 FERIVA iron bisgly&carbonyl/folic acid/vit c/cyanocobalamin/biotin ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 710 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 FUSION PLUS iron fum,polysac comp/folic acid/vit b compc no.18/l. casei ADD TO FORMULARY Non-Formulary Covered 05/24/2016 MAXFE iron carb,bg/methylfolate/b12/ma g ascorbate/biotin/zinc/dss ADD TO FORMULARY Non-Formulary Covered 05/24/2016 tl-hem 150 iron,carbonyl/docusate sodium/b12-if/folic acid/multivit-min ADD TO FORMULARY Non-Formulary Covered 05/24/2016 hemax iron,carbonyl/docusate sodium/b12-if/folic acid/multivit-min ADD TO FORMULARY Non-Formulary Covered 05/24/2016 HEMATRON-AF iron,carbonyl/docusate sodium/b12-if/folic acid/multivit-min ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ABATRON AF iron,carb/fa/vit c/vit e ac/b12/biotin/cupric sulf/docusate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ACTIVE FE iron,carbonyl/folic acid/multivitamin with minerals ADD TO FORMULARY 05/24/2016 ACTIVE FE iron,carbonyl/folic acid/multivitamin with minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 HEMOCYTE PLUS ferrous fumarate/folic acid/multivitamin-minerals no.15,ferrous fumarate/folic acid/multivitamins with min no. 15 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 centratex ferrous fumarate/folic acid/multivitamin-minerals no.15 ADD TO FORMULARY Non-Formulary Covered Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 711 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 ferrocite plus iron/folic acid/vitamin b comp and c/minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 hematinic plus iron/folic acid/vitamin b comp and c/minerals,iron/folic acid/vitamin b comp wc/minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 hematinic with folic acid ferrous fumarate/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 HEMOCYTE-F ferrous fumarate/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 PROFERRINFORTE iron heme polypeptide/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 INTEGRA F iron fumarate,polysac comp/folic acid/vitamin c/niacinamide ADD TO FORMULARY Non-Formulary Covered 05/24/2016 folivane-f iron fumarate,polysac comp/folic acid/vitamin c/niacinamide ADD TO FORMULARY Non-Formulary Covered 05/24/2016 FERRACTIV IRON iron amino acid chelate/cyanocobalamin/foli c acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 hemetab iron polysacchar complx/iron heme polypeptide/folic acid/b12 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 BIFERA RX iron polysacchar complx/iron heme polypeptide/folic acid/b12 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ferraplus 90 iron,carbonyl/folic acid/vitamin b12/vitamin c/docusate na ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 712 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 ferrex 28 iron asp.gly,fum/vit c/folic acid/m-vit no.11/calcium threon ADD TO FORMULARY Non-Formulary Covered 05/24/2016 natalvirt flt iron carbonyl,gluc/folic acid/vit b12/vit c/docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 FERRALET 90 iron carbonyl,gluc/folic acid/vit b12/vit c/docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 fe 90 plus iron carbonyl,gluc/folic acid/vit b12/vit c/docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 focalgin dss iron carbonyl,gluc/folic acid/vit b12/vit c/docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 FERIVA 21-7 iron asparto gly/folic ac/vitc/b12/zinc/docusate/su ccinic ac ADD TO FORMULARY Non-Formulary Covered 05/24/2016 LYDIA PINKHAM ferrous sulfate/licorice root HERBAL extract ADD TO FORMULARY Non-Formulary Covered 05/24/2016 IRO-PLEX iron ps/vit c/b12/b6/e acet/fa/intrinsic factor/senna leaf ADD TO FORMULARY Non-Formulary Covered 05/24/2016 LIVER WITH IRON ferrous fumarate/liver extract/vitamin b comp and c ADD TO FORMULARY Non-Formulary Covered 05/24/2016 iron with stool softener ferrous fumarate/docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 phillips magnesium oxide ADD TO FORMULARY Non-Formulary Covered 05/24/2016 laxative dietary supplement magnesium oxide ADD TO FORMULARY Non-Formulary Covered 05/24/2016 magnesium oxide magnesium oxide ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 713 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 UROMAG,URO- magnesium oxide MAG ADD TO FORMULARY Non-Formulary Covered 05/24/2016 magnesium magnesium oxide ADD TO FORMULARY Non-Formulary Covered 05/24/2016 magnesium magnesium oxide/magnesium amino acid chelate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 magnesium magnesium amino acid chelate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 magnesium citrate magnesium citrate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 mag-g magnesium gluconate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 magnesium gluconate magnesium gluconate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 MAGONATE magnesium gluconate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 magnesium magnesium amino acid chelate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 magnesium gluconate magnesium gluconate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 MAGONATE magnesium carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 magnesium sulfate magnesium sulfate in sterile water ADD TO FORMULARY Non-Formulary Covered 05/24/2016 magnesium sulfate magnesium sulfate in sterile water ADD TO FORMULARY Non-Formulary Covered 05/24/2016 magnesium sulfate magnesium sulfate in sterile water ADD TO FORMULARY Non-Formulary Covered 05/24/2016 magnesium sulfate magnesium sulfate in sterile water ADD TO FORMULARY Non-Formulary Covered 05/24/2016 magnesium sulfate magnesium sulfate in sterile water ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 714 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 magnesium sulfate magnesium sulfate ADD TO FORMULARY Covered 05/24/2016 magnesium sulfate magnesium sulfate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 magnesium sulfate-d5w magnesium sulfate/dextrose 5 % in water ADD TO FORMULARY Non-Formulary Covered 05/24/2016 magnesium dr magnesium chloride ADD TO FORMULARY Non-Formulary Covered 05/24/2016 MAG DELAY magnesium chloride ADD TO FORMULARY Non-Formulary Covered 05/24/2016 mag64 magnesium chloride ADD TO FORMULARY Non-Formulary Covered 05/24/2016 SLOW-MAG magnesium chloride ADD TO FORMULARY Non-Formulary Covered 05/24/2016 MAG GLYCINATE magnesium glycinate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 BEELITH magnesium oxide/pyridoxine hcl ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calciummagnesium-zinc calcium carbonate/magnesium oxide/copper/zinc oxide ADD TO FORMULARY Non-Formulary Covered 05/24/2016 potassium phosphate potassium phos,m-basic-dbasic ADD TO FORMULARY Non-Formulary Covered 05/24/2016 GLYCOPHOS sodium glycerophosphate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 PHOS-NAK sodium phosphate/potassium phosphates, monobasic and bibasic ADD TO FORMULARY Non-Formulary Covered 05/24/2016 biopetit vitamin b complex/lysine ADD TO FORMULARY Non-Formulary Covered 05/24/2016 APETEX vitamin b complex/lysine ADD TO FORMULARY Non-Formulary Covered 05/24/2016 APETIGEN vitamin b complex/lysine ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 715 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value vitamin b complex & vit c no.3,vitamin b complex with vitamin c combination no.3 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 b-complex with vit c,b complex with vitamin c 05/24/2016 VITA-BEE WITH b complex with vitamin c C ADD TO FORMULARY Non-Formulary Covered 05/24/2016 super b complex- b complex with vitamin c vitamin c ADD TO FORMULARY Non-Formulary Covered 05/24/2016 VITABEE W-C b complex with vitamin c ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin bb complex with vitamin c complex with vit c,b-complex with vitamin c,bcomplex plus vitamin c,bcomplex with c,b complex-vitamin c ADD TO FORMULARY Non-Formulary Covered 05/24/2016 superplex-t b complex with vitamin c ADD TO FORMULARY Non-Formulary Covered 05/24/2016 total b with c b complex with vitamin c ADD TO FORMULARY Non-Formulary Covered 05/24/2016 farbee w-c b complex with vitamin c ADD TO FORMULARY Non-Formulary Covered 05/24/2016 SUPER B WITH b complex with vitamin c VIT C,SUPER B COMPLEX WITH C ADD TO FORMULARY Non-Formulary Covered 05/24/2016 SUPPORT-500 b complex with vitamin c ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin bb complex with vitamin c complex with vit c ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin bb complex with vitamin c complex with vit c ADD TO FORMULARY Non-Formulary Covered 05/24/2016 super b complex vitamin b complex with vitamin c combination no.4 ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 716 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 balanced b complex-vit c vitamin b complex with vitamin c combination no.3 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin bcomplex & c b complex with vitamin c ADD TO FORMULARY Non-Formulary Covered 05/24/2016 stress 500 plus zinc multivitamin,stress formula/zinc ADD TO FORMULARY Non-Formulary Covered 05/24/2016 stress formula with zinc multivitamin,stress formula/zinc,multivits,stress formula/zinc ADD TO FORMULARY Non-Formulary Covered 05/24/2016 stress b with zinc multivitamin,stress formula/zinc ADD TO FORMULARY Non-Formulary Covered 05/24/2016 b-complex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 natural balanced vit b complex 100 combo b-100 no.2/herbal drugs ADD TO FORMULARY Non-Formulary Covered 05/24/2016 kobee vitamin b complex/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 b-complex 100,vitamin b100 complex vitamin b complex/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 balanced b-100 vitamin b complex/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 super quints vitamin b complex/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 super b maxi complex vitamin b complex/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin b-50 complex,vitamin b complex,bcomplex vitamin b complex/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 b-100 complex vit b complex 100 combo no.2 ADD TO FORMULARY 05/24/2016 b-100 complex vit b complex 100 combo no.2 ADD TO FORMULARY vitamin b comp and c/calcium carbonate Covered Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 717 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name vit b complex 100 combo no.2 Type of Change Previous Value New Value ADD TO FORMULARY Non-Formulary Covered 05/24/2016 balanced b100,b-100 complex 05/24/2016 COMPLEX B-50 calcium carbonate/vitamin b complex/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 complex b-100 vitamin b complex/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 b-50 complex vitamin b complex/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 stress 500 multivitamin,stress formula ADD TO FORMULARY Non-Formulary Covered 05/24/2016 stress-c multivitamin,stress formula ADD TO FORMULARY Non-Formulary Covered 05/24/2016 stress formula multivits,stress formula,multivitamin,stress formula,vitamin b complex/minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin bfolic acid/vitamin b complex complex with vit c and c/rice bran ADD TO FORMULARY Non-Formulary Covered 05/24/2016 b-complex with vitamin c,super vitamin b ADD TO FORMULARY 05/24/2016 super bfolic acid/vitamin b comp wcomplex,balance c,folic acid/vitamin b comp d band c complex,super-b complex,bcomplex with vitamin c,bcomplex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 DIALYVITE ADD TO FORMULARY Non-Formulary Covered 05/24/2016 NEPHRONEX-SL vitamin b complex with vitamin c no.19/folic acid/vitamin d3 ADD TO FORMULARY Non-Formulary Covered folic acid/vitamin b comp and c folic acid/vitamin b comp and c Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 718 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 VIRT-VITE PLUS folic acid/vitamin b complex with vitamin c no.17 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 folbee plus folic acid/vitamin b comp and c ADD TO FORMULARY Non-Formulary Covered 05/24/2016 NEPHRONEX vitamin b complex with vitamin c no.10/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 NEPHROCAPS QT vitamin b complex & vitamin c no.13/folic acid/vitamin d3,vitamin b complex with vitamin c no.13/folic acid/vitamin d3 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 DIALYVITE 800 WITH ZINC vitamin b complex & vit c/folic acid/zinc citrate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 DIALYVITE 800 WITH ZINC vitamin b complex & vit c/folic acid/zinc citrate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 SUPERVITE lysine hcl/vitamin b complex/folic acid/zinc ADD TO FORMULARY Non-Formulary Covered 05/24/2016 NUTRIVIT iron/lysine/vitamin b complex/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 DIALYVITE 3000 folic acid/vitamin b comp and c/selenium/min aa chel/zinc ADD TO FORMULARY Non-Formulary Covered 05/24/2016 folbee plus cz folic acid/vitamin b comp and c/copper/zinc oxide ADD TO FORMULARY Non-Formulary Covered 05/24/2016 stress formula with iron vit b complex/vit c/folic acid/ferrous fumarate/vit e acet ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin b complex vit b complex/vit c/folic acid/ferrous fumarate/vit e acet ADD TO FORMULARY Non-Formulary Covered 05/24/2016 stress formula with iron vit b complex/vit c/folic acid/ferrous sulfate/vit e acet ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 719 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 DIALYVITE 800- folic acid/vitamin b comp ULTRA D and c/zinc/vitamin d3 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 stress formula energy vit b comp c/ferrous fumarate/folic acid/vit e/amino acid 16 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 PRORENAL vit b cplx with c/ferrous fumarate/folic acid/vit d3/zinc ox ADD TO FORMULARY Non-Formulary Covered 05/24/2016 QUIN B STRONG vitamin b comp and c/folic acid/zinc ADD TO FORMULARY Non-Formulary Covered 05/24/2016 DIALYVITE SUPREME D multivitamins with min no.25/folic acid/vitamin d3 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 BALANCED B100 vit b complex 100 combo no.3/herbal drugs ADD TO FORMULARY Non-Formulary Covered 05/24/2016 alba-lybe lysine hcl/vitamin b complex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CARDIOTEK-RX folic acid/arginine hcl/cyanocobalamin/pyridoxi ne/pepper ext ADD TO FORMULARY Non-Formulary Covered 05/24/2016 folbee ar folic acid/arginine hcl/cyanocobalamin/pyridoxi ne/pepper ext ADD TO FORMULARY Non-Formulary Covered 05/24/2016 fatigue relief complex vitamin b comp and c/st.jhn wrt/siberian ginseng/p.ginsg ADD TO FORMULARY Non-Formulary Covered 05/24/2016 DIALYVITE 800 PLUS D vitamin b complex with c/folic acid/cholecalciferol (vit d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 stress formula vitamin b complex/minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 MEDTYCHOLL-B vitamin b complex/liver COMPLEX Wextract LIVER ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 720 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 stress formula with iron iron/multivitamin,stress formula,iron/multivits,stress formula ADD TO FORMULARY Non-Formulary Covered 05/24/2016 super b-50 complex vitamin b complex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin b complex vitamin b complex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin b complex vitamin b complex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 b-50 complex vitamin b complex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin b complex,b complex vitamin b complex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 b-100 complex vitamin b complex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin b complex vitamin b complex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 balanced b-50 vitamin b complex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 balance b-100 vitamin b complex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 b complex vitamin b complex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 bal b-50 vitamin b complex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 bal b-100 vitamin b complex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 balanced b-150 vitamin b complex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 natural b-100 vitamin b complex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 stress b vitamin b complex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ultra b-100 complex vitamin b complex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 b complete vitamin b complex ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 721 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 vitamin b complex vitamin b complex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 super quints vitamin b complex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 balanced b-50 vitamin b complex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 b complex # 1 vitamin b complex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 balanced b-100 vitamin b complex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 hi b complex vitamin b complex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 super b-50 complex plus vitamin b complex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 balance b-50 vitamin b complex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 b complex with b- vit 12 b2/niacinamide/pyridoxine hcl/cyanocobalamin/dpanthenol ADD TO FORMULARY Non-Formulary Covered 05/24/2016 b-complex thiamine hcl/riboflavin/niacinamide/de xpanthenol/pyridoxine ADD TO FORMULARY Non-Formulary Covered 05/24/2016 balanced b-50 vitamin b complex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 b-50 complex vitamin b complex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 balanced b-100 vitamin b complex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 b complex vitamin b complex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ultra b-100 complex vitamin b complex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 complex b-100 vitamin b complex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitacirc-b mecobalamin/levomefolate calcium/pyridoxal phosphate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 foltanx mecobalamin/levomefolate calcium/pyridoxal phosphate ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 722 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 l-methyl-b6-b12 mecobalamin/levomefolate calcium/pyridoxal phosphate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CEREFOLIN NAC levomefolate ca/acetylcysteine/mecobala min/schiz. algal oil ADD TO FORMULARY Non-Formulary Covered 05/24/2016 levomefola-nac- levomefolate mecobalm-algal,l- ca/acetylcysteine/mecobala methylfolatemin/schiz. algal oil mecobalaminnac,levomefolatenac-mecobalalgal ADD TO FORMULARY Non-Formulary Covered 05/24/2016 metafolbic plus rf levomefolate ca/acetylcysteine/mecobala min/schiz. algal oil ADD TO FORMULARY Non-Formulary Covered 05/24/2016 foltanx rf levomefolate ca/pyridoxal phos/mecobalamin/schiz. algal oil ADD TO FORMULARY Non-Formulary Covered 05/24/2016 levomefolpyridoxal-mecalgal levomefolate ca/pyridoxal phos/mecobalamin/schiz. algal oil ADD TO FORMULARY Non-Formulary Covered 05/24/2016 METANX levomefolate ca/pyridoxal phos/mecobalamin/schiz. algal oil ADD TO FORMULARY Non-Formulary Covered 05/24/2016 l-methylfolate ca levomefolate ca/pyridoxal p-5-p me-cbl phos/mecobalamin/schiz. algal oil ADD TO FORMULARY Non-Formulary Covered 05/24/2016 PODIAPN pyridoxal phos/methyltetrahydrofolate gluc/mecobalamin/ala ADD TO FORMULARY Non-Formulary Covered 05/24/2016 FOLGARD cholecalciferol/folic acid/riboflavin/pyridoxine hcl/vit b12 ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 723 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 vp-vite rx vitamin b complx no.3/folic acid/ascorbic acid/biotin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vol-care rx vitamin b complx no.3/folic acid/ascorbic acid/biotin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 rena-vite rx vitamin b complx no.3/folic acid/ascorbic acid/biotin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 NEPHRO-VITE RX vitamin b complx no.3/folic acid/ascorbic acid/biotin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 DIALYVITE ZINC vitamin b complex#11/folic acid/ascorbic acid/biotin/zn oxid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 NEPHPLEX RX vitamin b complx no.3/folic acid/ascorbic acid/biotin/znox ADD TO FORMULARY Non-Formulary Covered 05/24/2016 APETIGEN PLUS vitamin b complex/ferrous gluconate/zinc oxide/lysine ADD TO FORMULARY Non-Formulary Covered 05/24/2016 RABANO YODADO vitamin b complex no.12/niacinamide ADD TO FORMULARY Non-Formulary Covered 05/24/2016 brewer's yeast yeast, dried (saccharomyces cerevisiae),yeast ADD TO FORMULARY Non-Formulary Covered 05/24/2016 yeast yeast, dried (saccharomyces cerevisiae) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 BREWER'S YEAST yeast, dried (saccharomyces cerevisiae) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ECEE PLUS vitamin e acid succinate/ascorbic acid/mag sulf/zinc sulfate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 NICOMIDE methyltetrahydrofolate glucosamine/niacinamide/cu pric &zn ox ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 724 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 NICOMIDE levomefolate ca/niacinamide/copper/zinc/ selenium/chromium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 STRESS BCOMPLEX vitamin b comp w-c/fa/zinc sulfate/copper oxide/vitamin e ADD TO FORMULARY Non-Formulary Covered 05/24/2016 mega multi wmultivitamin with minerals chelated minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 one daily plus minerals multivitamin with minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 multivitamins with multivitamin with minerals minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 one daily energy multivitamin with minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 hair, skin and multivitamin with minerals nails,hair, skin & nails ADD TO FORMULARY Non-Formulary Covered 05/24/2016 icaps plus multivitamin with minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 mega multivitamin with minerals multivitamin with mineral ADD TO FORMULARY Non-Formulary Covered 05/24/2016 antioxidant vitamin multivitamin with minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 daily vitamin multivitamin with minerals formula-minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 one-a-day multivitamin with minerals maximum formula ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ONE DAILY COMPLETE multivitamin with minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 tab-a-viteminerals multivitamin with minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 multiple vitamin multivitamin with minerals ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 725 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 multivitamins with multivitamin with minerals minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 bee-zee multivitamin with minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 men's one daily multivitamin with minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 DIALYVITE 5000 multivitamins with minerals no.11/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 companion multivitamin with minerals/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 daily multiple multivitamin with minerals/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitalee multivitamin with minerals/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 daily multiple multivitamin with minerals/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 omnicap multivitamin with minerals/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 one daily essential multivitamin with minerals/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ONE-A-DAY multivitamin with minerals/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 men's daily formula multivitamin with minerals/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 quintabs-m iron free multivitamin with minerals/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 stress formula advanced multivitamin with minerals/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 one daily womens 50 plus folic acid/multivitamin wminerals,multivitamin with minerals/folic acid ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 726 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 men's daily formula multivitamin with minerals/folic acid/lycopene ADD TO FORMULARY Non-Formulary Covered 05/24/2016 men's one daily,one daily men's multivitamin with minerals/folic acid/lycopene ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ONE-A-DAY MEN'S multivitamin with minerals/folic acid/lycopene ADD TO FORMULARY Non-Formulary Covered 05/24/2016 one daily plus iron multivitamins with iron,multivitamin with iron ADD TO FORMULARY Non-Formulary Covered 05/24/2016 one daily multivitamin multivitamin with iron ADD TO FORMULARY Non-Formulary Covered 05/24/2016 multivitamins with multivitamin with iron iron ADD TO FORMULARY Non-Formulary Covered 05/24/2016 hair vitamin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 multivitamins with multivitamins with iron iron,multivitamin with iron ADD TO FORMULARY Non-Formulary Covered 05/24/2016 tab-a-vite with iron multivitamins with iron,multivitamin with iron ADD TO FORMULARY Non-Formulary Covered 05/24/2016 daily vitamin + iron multivitamin with iron,multivitamins with iron ADD TO FORMULARY Non-Formulary Covered 05/24/2016 DAILY VITE WITH IRON multivitamin with iron ADD TO FORMULARY Non-Formulary Covered 05/24/2016 one daily with iron multivitamin with iron,multivitamins with iron ADD TO FORMULARY Non-Formulary Covered 05/24/2016 daily multivitamin multivitamin with iron with iron ADD TO FORMULARY Non-Formulary Covered 05/24/2016 BIO-35 ADD TO FORMULARY Non-Formulary Covered multivitamin with iron mv,ca,min/ferrous fumarate/fa/lutein/lycopene/ herbal no.175 BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 727 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 AQUADEKS multivitamin with min no.52/folic acid/phytonadione/ubidecar ADD TO FORMULARY Non-Formulary Covered 05/24/2016 PRORENAL QD multivitamin with iron,other min/fa/d3/om-3/dha/epa/fish oil ADD TO FORMULARY Non-Formulary Covered 05/24/2016 multivitaminsa,b,d,e,k,zn multivitamins with min no.44/cholecalciferol (vit d3)/vit k ADD TO FORMULARY Non-Formulary Covered 05/24/2016 PROTECT PLUS multivit-min/methylfolate SO glucos/coenzyme q10/dietary no.26 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 PROTECT CARDIO AF multivit-min/methylfolate glucos/coenzyme q10/dha/epa/diet27 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 DAILY MULTIVITAMIN multivit with minerals/fa/vit k/lycopene/lutein/coenzyme q10 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ACTICAL calcium carbonate/magnesium oxide/vitamin d2/bioflavonoids ADD TO FORMULARY Non-Formulary Covered 05/24/2016 SUPER GINSENG MULTIVITAMIN multivitamin with minerals/ginseng ADD TO FORMULARY Non-Formulary Covered 05/24/2016 myvitalife multivitamin with minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 MEN'S DAILY FORMULA multivitamin with minerals/folic acid/lycopene ADD TO FORMULARY Non-Formulary Covered 05/24/2016 k-pax multivitamin, minerals, calcium, iron, and amino acids ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 728 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 k-pax multivitamin, minerals, calcium, iron, and amino acids ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vic-forte multivitamin-minerals no.7/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 v-c forte multivitamin-minerals no.7/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 BODY, HAIR, multivit,calcium,iron,min/fa/c SKIN AND NAILS hol bit/gelatin/inositol/paba ADD TO FORMULARY Non-Formulary Covered 05/24/2016 SUPER MULTIPLE multivitamin with minerals/folic acid/dietary suppl no.19 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 THERA-M multivit,therapeutic with iron/calcium/folic acid/minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 central vite multivitamin,multivits wfe,other min/ginkgo biloba extract/k.ginsg ADD TO FORMULARY Non-Formulary Covered 05/24/2016 complete multivits w-fe,other premium vitamin min/ginkgo biloba extract/k.ginsg ADD TO FORMULARY Non-Formulary Covered 05/24/2016 central-vite performance multivits w-fe,other min/ginkgo biloba extract/k.ginsg,multivit with fe,other mineral/ginkgo biloba extract/p.ginsg ADD TO FORMULARY Non-Formulary Covered 05/24/2016 multivital performance multivit with fe,other mineral/ginkgo biloba extract/p.ginsg ADD TO FORMULARY Non-Formulary Covered 05/24/2016 a thru z multivit,calcium,other min/ferrous fumarate/fa/lycopene/lut ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 729 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 sentry multivit,calcium,other min/ferrous fumarate/fa/lycopene/lut ADD TO FORMULARY Non-Formulary Covered 05/24/2016 complete multivit,calcium,other min/ferrous fumarate/fa/lycopene/lut ADD TO FORMULARY Non-Formulary Covered 05/24/2016 multivital multivit,calcium,other min/ferrous fumarate/fa/lycopene/lut ADD TO FORMULARY Non-Formulary Covered 05/24/2016 complete multi multivit,calcium,other min/ferrous fumarate/fa/lycopene/lut ADD TO FORMULARY Non-Formulary Covered 05/24/2016 VITATRUM multivit,calcium,other min/ferrous fumarate/fa/lycopene/lut ADD TO FORMULARY Non-Formulary Covered 05/24/2016 NUTRICAP folic acid/multivit with fe,other mineral ADD TO FORMULARY Non-Formulary Covered 05/24/2016 women's complex calcium/magnesium/vit b comp/vitamin d3/herbal complex no.61 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 century advanced multivits w-fe,other formula min/lutein,multivit with fe,other mineral/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 centrum silver ultra women's ADD TO FORMULARY Non-Formulary Covered 05/24/2016 essential balance multivits w-fe,other min/lutein,multivitamin,multiv it with fe,other mineral/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 theratrum complete multivit with fe,other mineral/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 a thru z select multivit with fe,other mineral/lutein ADD TO FORMULARY Non-Formulary Covered multivit with fe,other mineral/lutein BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 730 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 THEREMS-H multivit,th iron,other min ADD TO FORMULARY Non-Formulary Covered 05/24/2016 daily multiple multivitamin with iron,other mineral/green tea leaf extract ADD TO FORMULARY Non-Formulary Covered 05/24/2016 STROVITE ONE multivit with min#10/folic acid//vit d3/a lipoic acid/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 THERA M PLUS multivits, ca, minerals/iron fumarate/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 therapeutic-m multivits, ca, minerals/iron fumarate/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 thera-m multivits, ca, minerals/iron fumarate/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 one-a-day teen advantage multivits, ca, minerals/iron fumarate/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 one daily maximum folic acid/multivit with fe,other mineral,folic acid/multivits w-fe,other min ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ONE DAILY COMPLETE folic acid/multivit with fe,other mineral ADD TO FORMULARY Non-Formulary Covered 05/24/2016 one daily for women folic acid/multivit with fe,other mineral ADD TO FORMULARY Non-Formulary Covered 05/24/2016 century folic acid/multivit with fe,other mineral ADD TO FORMULARY Non-Formulary Covered 05/24/2016 essential daily multivit with calcium, iron, and other minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 therapeutic m multivit with calcium, iron, and other minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 maximum daily multivitamin multivit with calcium, iron, and other minerals ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 731 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 tab a vite multivit with calcium, iron, and other minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 women's daily multivitamin multivit with calcium, iron, and other minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 one daily maximum multivit with calcium, iron, and other minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 one daily multivitamin with iron,other mineral/green tea leaf extract ADD TO FORMULARY Non-Formulary Covered 05/24/2016 sentry senior multivitamin with minerals/folic acid/lycopene/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 century multivitamin with minerals/folic acid/lycopene/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 complete multivitamin multivitamin with minerals/folic acid/lycopene/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 adults' 50+ daily formula multivitamin with minerals/folic acid/lycopene/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 senior tabs multivitamin with minerals/folic acid/lycopene/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 central-vite senior multivitamin with minerals/folic acid/lycopene/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CERTAVITE SENIORANTIOXIDANT ADD TO FORMULARY Non-Formulary Covered multivitamin with minerals/folic acid/lycopene/lutein BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 732 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value multivitamin with minerals/folic acid/lycopene/lutein,multivita min w-minerals/folic acid/lycopene/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 central-vite 05/24/2016 spectravite adult multivitamin with 50+ minerals/folic acid/lycopene/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 a thru z select,a multivitamin with thru z select 50+ minerals/folic formula acid/lycopene/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 complete 50+ multivitamin with minerals/folic acid/lycopene/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 century mature formula,century mature multivitamin w-minerals/folic acid/lycopene/lutein,multivita min with minerals/folic acid/lycopene/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 abc plus multivitamin with minerals/folic acid/lycopene/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 spectravite advanced form multivitamin with minerals/folic acid/lycopene/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 centrum silver multivitamin with minerals/folic acid/lycopene/lutein,multivita min w-minerals/folic acid/lycopene/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 complete senior multivitamin with minerals/folic acid/lycopene/lutein ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 733 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 central-vite multivitamin with minerals/folic acid/lycopene/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 therapeutic-m folic acid/multivitamin with minerals/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ESSENTIAL WOMAN 50+ folic acid/multivitamin with minerals/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ESSENTIAL MAN multivitamin with minerals/folic acid/lycopene/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ESSENTIAL MAN 50+ multivitamin with minerals/folic acid/lycopene/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 certa plus folic acid/multivit with fe,other mineral/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 centravites folic acid/multivit,calcium,iron,&ot her mins/lycopene/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 multivital folic acid/multivit,calcium,iron,oth er mins/lycopene/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 FREEDAVITE multivitamin with minerals/ferrous fumarate/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 spectravite energy metabolism multivitamin-minerals/iron fumarate/folic acid/panax ginseng ADD TO FORMULARY Non-Formulary Covered 05/24/2016 central-vite performance multivitamin-minerals/iron fumarate/folic acid/panax ginseng ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 734 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 century energy metabolism multivitamin-minerals/iron fumarate/folic acid/panax ginseng ADD TO FORMULARY Non-Formulary Covered 05/24/2016 central-vite energy multivitamin-minerals/iron fumarate/folic acid/panax ginseng ADD TO FORMULARY Non-Formulary Covered 05/24/2016 century ultimate men's multivits w-ca, other min/iron/folic acid/lycopene ADD TO FORMULARY Non-Formulary Covered 05/24/2016 a thru z multivits w-ca, other min/iron/folic acid/lycopene ADD TO FORMULARY Non-Formulary Covered 05/24/2016 central-vite men's multivits w-ca, other under 50 min/iron/folic acid/lycopene ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CENTRUM ULTRA MEN'S multivits w-ca, other min/iron/folic acid/lycopene ADD TO FORMULARY Non-Formulary Covered 05/24/2016 spectravite men's multivits w-ca, other min/iron/folic acid/lycopene ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CENTRUM MEN multivits w-ca, other min/iron/folic acid/lycopene ADD TO FORMULARY Non-Formulary Covered 05/24/2016 complete men multivits w-ca, other min/iron/folic acid/lycopene ADD TO FORMULARY Non-Formulary Covered 05/24/2016 BACMIN multivitamins w-minerals combination no.20/iron/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 daily multiple multivitamin with minerals/folic acid/ginkgo leaf extract ADD TO FORMULARY Non-Formulary Covered 05/24/2016 women's 50+ daily formula multivitamin with minerals/folic acid/ginkgo leaf extract ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 735 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 one daily multivitamin with women's 50+,one minerals/folic acid/ginkgo daily,one daily for leaf extract women 50+ adv ADD TO FORMULARY Non-Formulary Covered 05/24/2016 one daily men's 50+ ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ULTRA FREEDA multivits, ca, minerals/iron fumarate/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 QUINTABS-M multivits, ca, minerals/iron fumarate/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ULTRA FREEDA multivitamin with calcium, minerals/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamins a-d-e vitamin a palmitate/betacarotene/vit d2/vit e/selenium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 diabetes health formula folic acid/multivitamin with minerals/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 VITRUM 50+ SENIOR multivitamin with minerals/folic acid/lycopene/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 complete multi 50+ multivitamin with minerals/folic acid/lycopene/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 sentry senior multivitamin with minerals/folic acid/lycopene/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 spectravite senior multivitamin with minerals/folic acid/lycopene/lutein ADD TO FORMULARY Non-Formulary Covered multivitamin with minerals/folic acid/ginkgo leaf extract BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 736 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 a thru z select multivitamin with minerals/folic acid/lycopene/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 multivital platinum multivitamin with minerals/folic acid/lycopene/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 century mature multivitamin with minerals/folic acid/lycopene/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 mega multi multivit w-ca, min/iron chelate/fa/lutein/herbal #179 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 mega multivitamin multivit w-ca, min/iron chelate/fa/lutein/herbal #179 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 mega multi,mega multivitamin with multivitamin minerals/folic acid/lycop/lut/herbal 178 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 theragran-m premier 50 plus multivitamin w-minerals/folic acid/co q10/lycopene/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 one daily diet support multivit,calcium,min/iron/folic acid/epigallocatechin/caff ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ultimate women's multivitamin with complete 50+ minerals/ferrous fumarat/folic acid/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 spectravite ultra women's multivitamin with minerals/ferrous fumarat/folic acid/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 century ultimate women's multivitamin with minerals/ferrous fumarat/folic acid/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 central-vite multivitamin with women's mature minerals/ferrous fumarat/folic acid/lutein ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 737 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 CENTRUM multivitamin with SILVER WOMEN minerals/ferrous fumarat/folic acid/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 women's daily multivits, ca, minerals/iron fumarate/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 THERA-TABS M multivits, ca, minerals/iron fumarate/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 k-pax immune support multivit with min/iron picolinate/fa/calcium/d3/ami no acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ONE-A-DAY WOMEN'S multivit,ca,min/ferrous fumarate/folic acid/guarana/caffeine ADD TO FORMULARY Non-Formulary Covered 05/24/2016 women's active multivit,ca,min/ferrous fumarate/folic acid/guarana/caffeine ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CENTRUM SILVER ULTRA MEN'S multivitamin with minerals/folic acid/lycopene/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 spectravite ultra men 50+ multivitamin with minerals/folic acid/lycopene/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 a thru z select multivitamin with minerals/folic acid/lycopene/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 spectravite ultra men's multivitamin with minerals/folic acid/lycopene/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 century ultimate men's multivitamin with minerals/folic acid/lycopene/lutein ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 738 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 ultimate men's complete 50+ multivitamin with minerals/folic acid/lycopene/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 hair, skin and nails multivit, ca, minerals/ferrous gluconate/folic acid/biotin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ONE-A-DAY MENOPAUSE FORMULA multivitamin with calcium, mineral/folic acid/soy isoflavone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ONE-A-DAY WOMEN'S HEALTHY SKIN multivitamin with calcium, minerals/iron/folic acid/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 MONOCAPS multivitamin with minerals/ferrous fumarate/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 women's 50+ daily formula multivitamin with minerals/folic acid/calcium carb/vit k1 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ONE-A-DAY WOMEN'S 50+ multivitamin with minerals/folic acid/calcium carb/vit k1 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 SUPER multivitamin with iron,other MULTIPLE-LOW min/fa/dietary supp comb. IRON no.24 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 mens 50+ advanced one daily multivitamin with minerals/folic acid/phytonadione/lycopene ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ONE-A-DAY multivitamin with MEN'S 50 PLUS minerals/folic acid/phytonadione/lycopene ADD TO FORMULARY Non-Formulary Covered 05/24/2016 SOLO ADD TO FORMULARY Non-Formulary Covered multivitamin with minerals/folic acid/phytonadione BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 739 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name multivit w-min/iron fumarate/folic acid/vit k/green tea xt Type of Change Previous Value New Value ADD TO FORMULARY Non-Formulary Covered 05/24/2016 PROCERV HP 05/24/2016 MULTI FOR HER multivit with calciummins/iron fumarate/folic acid/vit k ADD TO FORMULARY Non-Formulary Covered 05/24/2016 trueplus multivitamin multivitamin with minerals/folic acid/phytonadione ADD TO FORMULARY Non-Formulary Covered 05/24/2016 VITACEL multivitamin with minerals/folic acid/lycopene/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 BIOCEL multivitamin with minerals/folic acid/lycopene/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 HAIR, SKIN AND multivitamin with iron,other NAILS minerals/folic acid/biotin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 HAIR, SKIN AND multivitamin with NAILS minerals/folic acid/biotin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ocutabs beta-carotene (vit a) with vitamins c and e/minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 eye health plus lutein beta-carotene(a) w-c and e/lutein/minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vision beta-carotene (vit a) with vitamins c and e/minerals,multivitamin with minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 women's biomultiple multivitamin with minerals/herbal drugs ADD TO FORMULARY Non-Formulary Covered 05/24/2016 whole source multivitamin with minerals/herbal drugs ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 740 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 men's biomultiple multivitamin with minerals/herbal drugs ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin and minerals multivitamin,therapeutic with minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 super theravite-m multivitamins,ther wminerals,multivitamin,therap eutic with minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 MULTILEX ADD TO FORMULARY Non-Formulary Covered 05/24/2016 central-vite select multivitamin with minerals/lutein,multivitamin with iron and other minerals ADD TO FORMULARY 05/24/2016 central-vite select multivitamin with iron and other minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 UNICOMPLEX-M multivitamin with iron and other minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 COMPETE multivitamin with iron and other minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 super multiple multivitamin with iron and other minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 MULTILEX-T-M multivit,th iron,other min WITH MINERALS ADD TO FORMULARY Non-Formulary Covered 05/24/2016 complete multivitamin multivit,th iron,other min ADD TO FORMULARY Non-Formulary Covered 05/24/2016 thera-m multivits,th w-fe,other min,multivit,th iron,other min ADD TO FORMULARY Non-Formulary Covered 05/24/2016 multivitamins wcalcium-iron multivit with calcium, iron, and other minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 one daily with calcium-iron multivit with calcium, iron, and other minerals ADD TO FORMULARY Non-Formulary Covered multivitamin with iron and other minerals Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 741 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 multivitamins wcalcium-iron multivit with calcium, iron, and other minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 multiple vitamins multivit with calcium, iron, for women and other minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 STROVITE FORTE multivits, iron, minerals combo no #5, folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ICAPS MV multivitamin with minerals/folic acid/lutein/zeaxanthin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 one daily multivitamin with minerals/folic acid/lycopene ADD TO FORMULARY Non-Formulary Covered 05/24/2016 men's daily multivitmineral,men's multivitamin multivitamin with minerals/folic acid/lycopene ADD TO FORMULARY Non-Formulary Covered 05/24/2016 one daily for men,one daily men's health multivitamin with minerals/folic acid/lycopene ADD TO FORMULARY Non-Formulary Covered 05/24/2016 FOSFREE calcium/multivitamin with iron ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CORVITE FREE multivitamin with min no.6/folic acid/lutein/lycop/ubidecar ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ONE-A-DAY multivit, calcium, WEIGHTSMART iron,minerals/folic acid/herb complex 145 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 one daily healthy multivit, calcium, weight iron,minerals/folic acid/herb complex 145 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 one daily energy multivit,calcium,iron,mineral s/folic acid/guarana, caffeine ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 742 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value multivit,calcium,iron,mineral s/folic acid/guarana, caffeine ADD TO FORMULARY Non-Formulary Covered 05/24/2016 daily energy 05/24/2016 central-vite cardio multivit with calcium,iron,minerals/folic acid/phytosterol ADD TO FORMULARY Non-Formulary Covered 05/24/2016 century cardio multivit with calcium,iron,minerals/folic acid/phytosterol ADD TO FORMULARY Non-Formulary Covered 05/24/2016 centrum specialist heart multivit with calcium,iron,minerals/folic acid/phytosterol ADD TO FORMULARY Non-Formulary Covered 05/24/2016 spectravite cardio multivit with health calcium,iron,minerals/folic acid/phytosterol ADD TO FORMULARY Non-Formulary Covered 05/24/2016 century cardio health formula multivit with calcium,iron,minerals/folic acid/phytosterol ADD TO FORMULARY Non-Formulary Covered 05/24/2016 biotin pluscalcium & vit d3 multivitaminmins/calcium/biotin/cholecal ciferol/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 totalday multiple multivitamin with minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CENTRUM folic acid/multivit with fe,other mineral,folic acid/multivits w-fe,other min ADD TO FORMULARY Non-Formulary Covered 05/24/2016 AQUADEKS multivitamin with min no.51/folic acid/phytonadione/ubidecar ADD TO FORMULARY Non-Formulary Covered 05/24/2016 one daily gummy multivitamin with vites minerals/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 daily gummies ADD TO FORMULARY Non-Formulary Covered multivitamin with minerals/folic acid BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 743 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 womens daily gummies multivitamin with minerals/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 men's daily gummies multivitamin with minerals/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 men's multivitamin multivitamin with minerals/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 adult one daily gummies multivitamin with minerals/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 adult multivitamin multivitamin with gummies,adult minerals/folic acid multi gummies ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ONE-A-DAY multivitamin with VITACRAVES,O minerals/folic acid NE-A-DAY VITACRAVES SOUR ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ONE-A-DAY MEN VITACRAVES multivitamin with minerals/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ONE-A-DAY WOMEN VITACRAVES multivitamin with minerals/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ONE-A-DAY VITACRAVES IMMUNITY multivitamin with minerals/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 spectravite adult multivitamin with minerals/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 women's multivitamin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 adult multivitamin folic acid/multivitamin with gummies minerals/lutein ADD TO FORMULARY Non-Formulary Covered multivitamin with minerals/folic acid BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 744 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 multi-vitamin folic acid/multivitamin with minerals/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 OPTISOURCE multivit with calciummins/iron fumarate/folic acid/vit k ADD TO FORMULARY Non-Formulary Covered 05/24/2016 OPURITY MULTIVITAMIN iron,carbonyl/folic acid/multivitamin with minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 BEROCCA multivitamin with minerals/folic acid/guarana/caffeine ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CEROVITE multivitamin with minerals/ferrous gluconate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 centamin multivitamin with minerals/ferrous gluconate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 centram-care multivitamin with minerals/ferrous gluconate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 centrum multivitamin with minerals/ferrous gluconate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 certaviteantioxidant multivitamin with minerals/ferrous gluconate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 multivitamins with multivitamin with minerals minerals/ferrous gluconate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 complete multivitaminmineral multivitamin with minerals/ferrous fumarate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 multivitamin multivitamin with minerals/ferrous fumarate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 tyr cooler amino acids/multivits,th wfe,other min ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 745 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 PROTECT PLUS amino acids/multivits,th wfe,other min ADD TO FORMULARY Non-Formulary Covered 05/24/2016 biotect plus amino acids/multivits,th wfe,other min ADD TO FORMULARY Non-Formulary Covered 05/24/2016 biosupp multivitamin with minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 APATATE FORTE multivitamin with minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 support multivitamin with minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 biovol multivitamin with minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 MAXIMIN folic acid/multivitamin with minerals/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 LIFE-PACK multivitamin with iron and other minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 LIFE-PACK bioflavonoids/multivit with fe,other mineral ADD TO FORMULARY Non-Formulary Covered 05/24/2016 DIABETES HEALTH alpha lipoic acid/folic acid/multivitamin with minerals/lut ADD TO FORMULARY Non-Formulary Covered 05/24/2016 MEN'S PACK folic acid/multivitamin with minerals/lutein ADD TO FORMULARY Non-Formulary Covered 05/24/2016 THERANATAL LACTATION SUPPORT multivit with min/iron/folic acid/k/d3/choline/dha/fish oil ADD TO FORMULARY Non-Formulary Covered 05/24/2016 UDAMIN SP multivitamins with min no.9/folic acid/saw palmetto extract ADD TO FORMULARY Non-Formulary Covered 05/24/2016 MULTICHEW multivits, iron, minerals combo no #4, folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 SUPERVITE EC multivitamins with min no.21/folic acid ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 746 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name multivitamin-minerals/iron fum/folic acid/calcium carb/vit k Type of Change Previous Value New Value ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ONE-A-DAY WOMEN'S 05/24/2016 advanced am/pm omega-3 fatty acids/calcium carb/vitamin d3/fa/mv cmb 13 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ONE-A-DAY VITACRAVES OMEGA-3 multivitamin/folic acid/docosahexanoic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 MULTI-DELYN multivitamin/ferrous gluconate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CENTRUM SPECIALIST ENERGY multivitamin-minerals/iron fumarate/fa/vit k/korean ginseng ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamins for hair mv,iron,min/folic acid/inositol/chol bitart/paba ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ICAPS riboflavin/beta-carotene(a) w-c and e/lutein/zeaxanthin/min,ribofl avin/beta-carotene(a) w-c & e/lutein/zeaxanthin/min ADD TO FORMULARY Non-Formulary Covered 05/24/2016 multivitamins with multivitamin,therapeutic with minerals hp minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium citrate + d calcium citrate/magnesium oxide/vitamin d3/pyridoxine/min ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium citrate plus calcium citrate/magnesium oxide/vitamin d3/pyridoxine/min ADD TO FORMULARY Non-Formulary Covered 05/24/2016 BLADDER 2.2 multivitamin with minerals/folic acid/lycopene/boron ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 747 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 vitamin d3-aloe ca comb no.1/vitamin d3/pyridoxine hcl/fa/vit b12/aloe vera ADD TO FORMULARY Non-Formulary Covered 05/24/2016 HEARTBURN & ACID REFLUX ca comb no.1/vitamin d3/pyridoxine hcl/fa/vit b12/aloe vera ADD TO FORMULARY Non-Formulary Covered 05/24/2016 PROTECT IRON multivitamin-minerals no.24/iron polysaccharide complex/fa ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CARDIAMIN multivitamin with min/folic acid/d3/omega3/dha/epa/fish oil ADD TO FORMULARY Non-Formulary Covered 05/24/2016 DIABETES HEALTH PACK mv,ca,mn/k/omega-3/vit d3/mag/c/alip acid/green tea/chromium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 OXI-FREEDA multivitamin with minerals/glutathione/cystein e ADD TO FORMULARY Non-Formulary Covered 05/24/2016 MACULAR VITAMIN multivitamin with minerals/folic acid/lutein/zeaxanthin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 THERAMILL FORTE multivit-min/folic acid/inositol/choline bit/bioflav,citrus ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ONE-A-DAY VITACRAVES ENERGY multivitamin with minerals/folic acid/caffeine ADD TO FORMULARY Non-Formulary Covered 05/24/2016 antioxidant beta-carotene (vit a) with vitamins c and e/minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 antioxidant formula beta-carotene (vit a) with vitamins c and e/minerals ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 748 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 superior 35 multivitamin with iron and other minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ELDERCAPS multivitamin-minerals no.5/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 BIO-35 multivit,calcium,iron,min/fa/l utein/lycopene/herbal no.153 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin e vitamin e acetate/selenium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin a and d vitamins a and d ADD TO FORMULARY Non-Formulary Covered 05/24/2016 DIALYVITE 800 WITH IRON ferrous fumarate/folic acid/vitamin b comp and c ADD TO FORMULARY Non-Formulary Covered 05/24/2016 multivitamins multivitamin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 one daily multivitamin multivitamin with folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 QUINTABS multivitamin with folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 one daily essential multivitamin with folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 one daily multivitamin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 daily vite multivitamin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 one daily essential multivitamin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 one-a-day essential multivitamin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 one daily multivitamin multivitamin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 daily value multivitamin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 pharmacist multivitamin favorite multi-vite ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 749 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 SUPER MULTIVITAMIN multivitamin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 men's multivitamin multivitamin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 multivitamins multivitamin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 daily multiple vitamin multivitamin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 VITAMINS FOR HAIR iron/vitamin b complex/minerals,multivitam in ADD TO FORMULARY Non-Formulary Covered 05/24/2016 once daily multivitamin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 daily vitamin multivitamin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 daily vitamin formula multivitamin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 multi-vitamin daily,daily multiple vitamin multivitamin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 tab-a-vite multivitamin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 multiple vitamins multivitamin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 multiple vitamins multivitamin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 THEREMS multivitamin,therapeutic ADD TO FORMULARY Non-Formulary Covered 05/24/2016 thera-tabs multivitamin,therapeutic ADD TO FORMULARY Non-Formulary Covered 05/24/2016 thera multivitamins,therapeutic,mu ltivitamin,therapeutic ADD TO FORMULARY Non-Formulary Covered 05/24/2016 thera multivitamin,therapeutic ADD TO FORMULARY Non-Formulary Covered 05/24/2016 oncovite multivitamin,therapeutic ADD TO FORMULARY Non-Formulary Covered 05/24/2016 M.V.I. ADULT mvi, adult no.1 with vit k ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 750 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name mvi, adult no.4 with vit k Type of Change Previous Value New Value ADD TO FORMULARY Non-Formulary Covered 05/24/2016 INFUVITE ADULT 05/24/2016 complete women multivitamin/ferrous fumarate/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 spectravite ultra women multivitamin/ferrous fumarate/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 multi-day plus iron multivitamin/ferrous fumarate/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 central-vite multivitamin/ferrous fumarate/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 one-a-day teen advantage multivitamin/ferrous fumarate/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 adults' daily formula multivitamin/ferrous fumarate/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 certaviteantioxidant multivitamin/ferrous fumarate/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 spectravite advanced formula multivitamin/ferrous fumarate/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 essentia multivitamin/ferrous fumarate/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 one daily multivitamin-iron multivitamin/ferrous fumarate/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 a thru z advanced formula multivitamin/ferrous fumarate/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 multi completeiron multivitamin/ferrous fumarate/folic acid ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 751 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 complete multimultivitamin/ferrous vitfumarate/folic acid mineral,complete multivitamin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 multi-vite multivitamin/ferrous fumarate/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 daily vitamin formula + iron multivitamin/ferrous fumarate/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 sentry multivitamin/ferrous fumarate/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 daily multivitamin- multivitamin/ferrous iron fumarate/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CEROVITE ADVANCED FORMULA multivitamin/ferrous fumarate/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 century ultimate women's multivitamin/ferrous fumarate/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ONE DAILY PLUS IRON multivitamin/ferrous fumarate/folic acid ADD TO FORMULARY 05/24/2016 one daily with iron,one daily plus iron multivitamin/ferrous fumarate/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 century multivitamin/ferrous fumarate/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 yelets multivitamin/ferrous fumarate/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 daily multiple multivitamin/ferrous fumarate/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 centrum complete multivitamin/ferrous fumarate/folic acid ADD TO FORMULARY Non-Formulary Covered Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 752 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 FORTAVIT multivit with fe,other mineral/dietary 4/dna/rna ADD TO FORMULARY Non-Formulary Covered 05/24/2016 DECUBI VITE multivitamin/folic acid/zinc sulfate/ascorbic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 daily multiple multivitamins wminerals/folic acid/lycopene/ginkgo leaf xt ADD TO FORMULARY Non-Formulary Covered 05/24/2016 one daily men's 50+ multivitamins wminerals/folic acid/lycopene/ginkgo leaf xt ADD TO FORMULARY Non-Formulary Covered 05/24/2016 one daily for men multivitamins w50+ advanced minerals/folic acid/lycopene/ginkgo leaf xt ADD TO FORMULARY Non-Formulary Covered 05/24/2016 daily multiple multivits, ca, minerals/iron fumarate/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 central-vite women's under 50 multivits, ca, minerals/iron fumarate/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ONE-A-DAY WOMEN'S multivits, ca, minerals/iron fumarate/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 women's one daily,one daily women's multivits, ca, minerals/iron fumarate/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 women's daily formula multivits, ca, minerals/iron fumarate/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ONE-A-DAY multivitamins wMEN'S 50 PLUS minerals/folic acid/lycopene/ginkgo leaf xt ADD TO FORMULARY Non-Formulary Covered 05/24/2016 men's 50+ daily formula ADD TO FORMULARY Non-Formulary Covered multivitamins wminerals/folic acid/lycopene/ginkgo leaf xt BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 753 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 one daily women's health multivits, ca, minerals/iron fumarate/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 one daily women's multivits, ca, minerals/iron fumarate/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ONE-A-DAY ENERGY multivit,ca,min/ferrous fumarate/folic acid/guarana/caffeine ADD TO FORMULARY Non-Formulary Covered 05/24/2016 one daily energy multivit,ca,min/ferrous fumarate/folic acid/guarana/caffeine ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ONE-A-DAY WOMEN'S PETITES multivits, ca, minerals/iron fumarate/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 KENWOOD THERAPEUTIC multivitamin,therapeutic ADD TO FORMULARY Non-Formulary Covered 05/24/2016 diabetes health support multivitamin with calcium &other minerals/fa/bioflavonoids#4 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 chewable multi vitamin multivitamin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CHEWABLEVITE multivitamin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 my favorite multiple multivitamin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 multi-delyn multivitamin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CEREFOLIN cyanocobalamin/levomefolat e calcium/pyridoxine/riboflavin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 l-methyl-mc cyanocobalamin/levomefolat e calcium/pyridoxine/riboflavin ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 754 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 metafolbic cyanocobalamin/levomefolat e calcium/pyridoxine/riboflavin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vit 3 omega-3/dha/epa/b12/folic acid/pyridoxine hcl/phytosterols ADD TO FORMULARY Non-Formulary Covered 05/24/2016 bp vit 3 plus omega3/dha/epa/d3/b12/folic acid/pyridox hcl/phytosterol ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ANIMI-3 WITH VITAMIN D,ANIMI-3 omega3/dha/epa/d3/b12/folic acid/pyridox hcl/phytosterol ADD TO FORMULARY Non-Formulary Covered 05/24/2016 se-tan plus iron fumarate-iron polysacch cplex/folic acid/multivit no.18 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 purevit dualfe plus iron fumarate-iron polysacch cplex/folic acid/multivit no.18 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 TANDEM PLUS iron fumarate-iron polysacch cplex/folic acid/multivit no.18 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 tri-vita pediatric multivitamin a,c,and d3 no.21 CHANGE UM: QUANTITY 2 / Day 2 / Day 05/24/2016 tri-vita pediatric multivitamin a,c,and d3 no.21 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 tri-vitamin pediatric multivitamin a,c,and d3 no.21,pediatric multivitamins a,c,& d3 no.21 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 tri-vitamin pediatric multivitamin a,c,and d3 no.21,pediatric multivitamins a,c,& d3 no.21 CHANGE UM: QUANTITY 2 / Day 2 / Day 05/24/2016 poly-vita pediatric multivitamin no.20 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 poly-vitamin pediatric multivitamin no.20 ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 755 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 tri-vitamin with fluoride pediatric multivitamins a,c,& d3 no.21 with sodium fluoride ADD TO FORMULARY Non-Formulary Covered 05/24/2016 tri-vitamin with fluoride pediatric multivitamins a,c,& d3 no.21 with sodium fluoride CHANGE UM: QUANTITY 2 / Day 2 / Day 05/24/2016 triple-vitamin wfluoride pediatric multivitamins a,c,& d3 no.21 with sodium fluoride CHANGE UM: QUANTITY 2 / Day 2 / Day 05/24/2016 triple-vitamin wfluoride pediatric multivitamins a,c,& d3 no.21 with sodium fluoride ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamins a,c,d & fluoride,vitamins a,d,c & fluoride pediatric multivitamins a,c,& d3 no.21 with sodium fluoride CHANGE UM: QUANTITY 2 / Day 2 / Day 05/24/2016 vitamins a,c,d & fluoride,vitamins a,d,c & fluoride pediatric multivitamins a,c,& d3 no.21 with sodium fluoride ADD TO FORMULARY Non-Formulary Covered 05/24/2016 B-COMPLEX WITH B-12 thiamine hcl/riboflavin/niacinamide/cy anocobalamin/protease ADD TO FORMULARY Non-Formulary Covered 05/24/2016 b complex with vitamin c thiamine m.nit/riboflavin/niacin/ca pantothenate/b6/b12/c/fa ADD TO FORMULARY Non-Formulary Covered 05/24/2016 VITA-RESPA cyanocobalamin/folic acid/pyridoxine ADD TO FORMULARY Non-Formulary Covered 05/24/2016 folbic cyanocobalamin/folic acid/pyridoxine ADD TO FORMULARY 05/24/2016 folbic cyanocobalamin/folic acid/pyridoxine ADD TO FORMULARY Non-Formulary Covered 05/24/2016 virt-vite forte cyanocobalamin/folic acid/pyridoxine ADD TO FORMULARY Non-Formulary Covered Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 756 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name cyanocobalamin/folic acid/pyridoxine Type of Change Previous Value New Value ADD TO FORMULARY Non-Formulary Covered 05/24/2016 niva-fol 05/24/2016 lmthf-pyridoxine- cyanocobalamin/levomefolat cyanocobal e calcium/pyridoxine hcl ADD TO FORMULARY Non-Formulary Covered 05/24/2016 cyanocoballevomefpyridoxine cyanocobalamin/levomefolat e calcium/pyridoxine hcl ADD TO FORMULARY Non-Formulary Covered 05/24/2016 folbic rf cyanocobalamin/levomefolat e calcium/pyridoxine hcl ADD TO FORMULARY Non-Formulary Covered 05/24/2016 FOLTX cyanocobalamin/levomefolat e calcium/pyridoxine hcl ADD TO FORMULARY Non-Formulary Covered 05/24/2016 foltabs 800 cyanocobalamin/folic acid/pyridoxine ADD TO FORMULARY Non-Formulary Covered 05/24/2016 fabb cyanocobalamin/folic acid/pyridoxine ADD TO FORMULARY Non-Formulary Covered 05/24/2016 tl gard rx cyanocobalamin/folic acid/pyridoxine ADD TO FORMULARY Non-Formulary Covered 05/24/2016 FOLGARD RX cyanocobalamin/folic acid/pyridoxine ADD TO FORMULARY Non-Formulary Covered 05/24/2016 virt-gard cyanocobalamin/folic acid/pyridoxine ADD TO FORMULARY Non-Formulary Covered 05/24/2016 AV-VITE FB cyanocobalamin/folic acid/pyridoxine ADD TO FORMULARY 05/24/2016 AV-VITE FB cyanocobalamin/folic acid/pyridoxine ADD TO FORMULARY Non-Formulary Covered 05/24/2016 folbee cyanocobalamin/folic acid/pyridoxine ADD TO FORMULARY Non-Formulary Covered 05/24/2016 virt-vite cyanocobalamin/folic acid/pyridoxine ADD TO FORMULARY Non-Formulary Covered 05/24/2016 FOLINIC-PLUS leucovorin calcium/pyridoxal phosphate/mecobalamin ADD TO FORMULARY Non-Formulary Covered Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 757 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 HOMOCYSTEIN cyanocobalamin/folic E FORMULA acid/pyridoxine ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ARKALIOX sulbutiamine ADD TO FORMULARY Non-Formulary Covered 05/24/2016 biotin biotin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 biotin biotin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 HARD NAILS biotin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 MERIBIN biotin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 biotin biotin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 mega biotin biotin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 biotin biotin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 biotin biotin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 biotin biotin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 biotin biotin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 biotin biotin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CYTO B7 biotin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin d3 cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin d3 cholecalciferol (vitamin d3) ADD UM: AGE 05/24/2016 vitamin d3,vitamin d cholecalciferol (vitamin d3) ADD TO FORMULARY 05/24/2016 vitamin d3,vitamin d cholecalciferol (vitamin d3) ADD UM: AGE At least 65 yrs old 05/24/2016 vitamin d3 cholecalciferol (vitamin d3) ADD TO FORMULARY Covered 05/24/2016 vitamin d3,vitamin d cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin d3,vitamin d cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered At least 65 yrs old Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 758 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 vitamin d3 cholecalciferol (vitamin d3) ADD TO FORMULARY Covered 05/24/2016 vitamin d3 cholecalciferol (vitamin d3) ADD TO FORMULARY 05/24/2016 vitamin d3 cholecalciferol (vitamin d3) ADD TO FORMULARY 05/24/2016 vitamin d3,vitamin d cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 dialyvite vitamin d cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin d3 cholecalciferol (vitamin d3) ADD TO FORMULARY 05/24/2016 vitamin d3 cholecalciferol (vitamin d3) ADD TO FORMULARY 05/24/2016 vitamin d3 cholecalciferol (vitamin d3) ADD TO FORMULARY 05/24/2016 vitamin d3 cholecalciferol (vitamin d3) ADD TO FORMULARY 05/24/2016 vitamin d3 cholecalciferol (vitamin d3) ADD UM: AGE At least 65 yrs old 05/24/2016 vitamin d3,vitamin d,vitamin d-400 cholecalciferol (vitamin d3) ADD UM: AGE At least 65 yrs old 05/24/2016 vitamin d3,vitamin d,vitamin d-400 cholecalciferol (vitamin d3) ADD TO FORMULARY 05/24/2016 delta d3 cholecalciferol (vitamin d3) ADD UM: AGE 05/24/2016 delta d3 cholecalciferol (vitamin d3) ADD TO FORMULARY 05/24/2016 vitamin d3 cholecalciferol (vitamin d3) ADD TO FORMULARY 05/24/2016 vitamin d3 cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin d3 cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 kids vitamin d3 cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin d3 cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin d3,vitamin d cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered Non-Formulary Covered Covered Covered Non-Formulary Covered Covered Non-Formulary Non-Formulary Covered Covered At least 65 yrs old Non-Formulary Covered Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 759 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 vitamin d3 cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 d-vita cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 JUST D cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 d-vi-sol cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 VITAL-D RX vit b complx no.4/cholecalciferol/ascorbic acid/fa/zinc ox ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin e vitamin e ADD TO FORMULARY Non-Formulary Covered 05/24/2016 e-200 vitamin e (dl-alpha tocopheryl acetate) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin e vitamin e (dl-alpha tocopheryl acetate) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin e vitamin e acetate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin e vitamin e,vitamin e acetate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin e vitamin e (dl-alpha tocopheryl acetate) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin e vitamin e mixed ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin e vitamin e,vitamin e acetate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin e vitamin e (dl-alpha tocopheryl acetate) ADD TO FORMULARY 05/24/2016 vitamin e vitamin e (dl-alpha tocopheryl acetate) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin e natural vitamin e mixed blend ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin e vitamin e,vitamin e acetate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin e vitamin e mixed ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin e vitamin e mixed ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin e vitamin e acid succinate ADD TO FORMULARY Non-Formulary Covered Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 760 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 LIQUI-E tocophersolan ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin e vitamin e acetate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin eoil,vitamin e vitamin e (dl-alpha tocopheryl acetate) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin e vitamin e (dl-alpha tocopheryl acetate) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin e vitamin e ADD TO FORMULARY Non-Formulary Covered 05/24/2016 aquasol e vitamin e ADD TO FORMULARY Non-Formulary Covered 05/24/2016 wheat germ oil wheat germ oil ADD TO FORMULARY Non-Formulary Covered 05/24/2016 AQUA-E vitamin e mixed/tocotrienol ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin e vitamin e ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin e vitamin e mixed ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin e vitamin e mixed ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin e vitamin e acid succinate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin e vitamin e acid succinate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin e vitamin e,vitamin e acetate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 wheat germ oil wheat germ oil ADD TO FORMULARY Non-Formulary Covered 05/24/2016 POTABA potassium aminobenzoate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 antacid tablet magnesium trisilicate/al hydrox/sod bicarb/alginic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 foaming antacid magnesium trisilicate/al hydrox/sod bicarb/alginic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 GAVISCON magnesium trisilicate/al hydrox/sod bicarb/alginic acid ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 761 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name aluminum hydroxide Type of Change Previous Value New Value ADD TO FORMULARY Non-Formulary Covered 05/24/2016 aluminum hydroxide 05/24/2016 ALKA-SELTZER potassium bicarbonate/sodium bicarbonate/citric acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 MAG-AL magnesium hydroxide/aluminum hydroxide ADD TO FORMULARY Non-Formulary Covered 05/24/2016 acid gone magnesium carbonate/aluminum hydroxide ADD TO FORMULARY Non-Formulary Covered 05/24/2016 GAVISCON magnesium carbonate/aluminum hydroxide ADD TO FORMULARY Non-Formulary Covered 05/24/2016 antacid extra strength magnesium carbonate/aluminum hydroxide ADD TO FORMULARY Non-Formulary Covered 05/24/2016 heartburn antacid magnesium carbonate/aluminum hydroxide ADD TO FORMULARY Non-Formulary Covered 05/24/2016 foaming antacid magnesium carbonate/aluminum hydroxide ADD TO FORMULARY Non-Formulary Covered 05/24/2016 heartburn relief magnesium carbonate/aluminum hydroxide ADD TO FORMULARY Non-Formulary Covered 05/24/2016 GAVISCON magnesium carbonate/aluminum hydroxide/alginic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 acid gone antacid magnesium carbonate/aluminum hydroxide/alginic acid ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 762 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 foaming antacid magnesium carbonate/aluminum hydroxide/alginic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 RIGINIC magnesium carbonate/aluminum hydroxide/alginic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 GAVISCON magnesium carbonate/aluminum hydroxide/alginic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ROLAIDS calcium carbonate/magnesium hydroxide ADD TO FORMULARY Non-Formulary Covered 05/24/2016 antacid calcium carbonate/magnesium hydroxide ADD TO FORMULARY Non-Formulary Covered 05/24/2016 antacid,antacid extra strength calcium carbonate/magnesium hydroxide ADD TO FORMULARY Non-Formulary Covered 05/24/2016 mi-acid ds calcium carbonate/magnesium hydroxide ADD TO FORMULARY Non-Formulary Covered 05/24/2016 antacid calcium carbonate/magnesium hydroxide ADD TO FORMULARY Non-Formulary Covered 05/24/2016 supreme antacid calcium carbonate/magnesium hydroxide ADD TO FORMULARY Non-Formulary Covered 05/24/2016 antacid supreme calcium carbonate/magnesium hydroxide ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ALKA-SELTZER sodium bicarbonate/sodium HEARTBURN citrate ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 763 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value Non-Formulary Covered 05/24/2016 sodium bicarbonate sodium bicarbonate ADD TO FORMULARY 05/24/2016 calcium carbonate calcium carbonate ADD TO FORMULARY 05/24/2016 calcium carbonate calcium carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 antacid calcium calcium carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium antacid calcium carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 antacid ultra strength calcium carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 tums ultra strength calcium carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 PRELIEF calcium glycerophosphate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 flanax magnesium hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 antacid m magnesium hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 comfort gel magnesium hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 mi acid magnesium hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 antacid-antigas magnesium hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 764 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 advanced magnesium antacidhydroxide/aluminum antigas,advanced hydroxide/simethicone antacid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ALMACONE magnesium hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ri-mox magnesium hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 MAG-AL PLUS magnesium hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 antacid plus anti- magnesium gas,antacidhydroxide/aluminum antigas hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 geri-mox magnesium hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 antacid magnesium hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 MAALOX ADVANCED magnesium hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 RULOX magnesium hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 antacid magnesium hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 765 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 antacid-antigas magnesium hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ri-gel magnesium hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 liquid antacid magnesium hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 antacid magnesium hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 antacid with simethicone magnesium hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 geri-lanta magnesium hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 antacid magnesium hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 mintox magnesium hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 maglox magnesium hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 antacid-antigas calcium carbonate/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 MAALOX ADVANCED calcium carbonate/simethicone ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 766 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 ALMACONE magnesium hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 mintox plus magnesium hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 GELUSIL magnesium hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 maalox maximum magnesium strength hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 antacid-antigas magnesium hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 antacid with simethicone magnesium hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 mi-acid magnesium hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 almacone-2 magnesium hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 masanti magnesium hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 mag-al plus xs magnesium hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ri-gel ii magnesium hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 767 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 antacid ii plus simethicone magnesium hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 comfort gel magnesium hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 gelusil magnesium hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 liquid antacid magnesium hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 antacid extra strength magnesium hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 antacid maximum magnesium strength hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY 05/24/2016 antacid,antacid magnesium maximum hydroxide/aluminum strength,advance hydroxide/simethicone d antacid-antigas ADD TO FORMULARY Non-Formulary Covered 05/24/2016 mintox maximum magnesium strength hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 antacid plus anti- magnesium gas hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 antacid anti-gas double str ADD TO FORMULARY Non-Formulary Covered magnesium hydroxide/aluminum hydroxide/simethicone Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 768 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 advanced antacid-antigas magnesium hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 antacidmagnesium antigas,antacid & hydroxide/aluminum antigas,antacid & hydroxide/simethicone gas relief ADD TO FORMULARY Non-Formulary Covered 05/24/2016 antacid multisymptom calcium carbonate/magnesium hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 E-Z-GAS II simethicone/sodium bicarbonate/citric acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ALKA-SELTZER calcium HEARTBURN+G carbonate/simethicone AS ADD TO FORMULARY Non-Formulary Covered 05/24/2016 antacid ii with simethicone magnesium hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 antacid-antigas magnesium hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ri-mox plus magnesium hydroxide/aluminum hydroxide/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ri mag plus magaldrate/simethicone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 dewee's carminative magnesium carbonate/asafetida ADD TO FORMULARY Non-Formulary Covered 05/24/2016 AMITIZA lubiprostone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 AMITIZA lubiprostone ADD TO FORMULARY Non-Formulary Covered 05/24/2016 UNIFIBER cellulose ADD TO FORMULARY Non-Formulary Covered 05/24/2016 fiber supplement inulin/sorbitol ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 769 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 fiber,weight management fiber inulin/sorbitol ADD TO FORMULARY Non-Formulary Covered 05/24/2016 fiber select gummies inulin/chromium picolinate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 fiber gummies inulin/chromium picolinate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 FIBER CHOICE inulin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 child's fiber select inulin gummies ADD TO FORMULARY Non-Formulary Covered 05/24/2016 LIQUAFIBER glycerin/maltodextrin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 HYFIBER WITH FOS fructooligosaccharides/polyd extrose ADD TO FORMULARY Non-Formulary Covered 05/24/2016 fiber dextrin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 easy fiber dextrin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CITRUCEL methylcellulose ADD TO FORMULARY Non-Formulary Covered 05/24/2016 FIBER THERAPY methylcellulose (with sugar) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CITRUCEL methylcellulose (with sugar) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 psyllium fiber psyllium husk ADD TO FORMULARY Non-Formulary Covered 05/24/2016 fiber psyllium husk ADD TO FORMULARY Non-Formulary Covered 05/24/2016 fiber psyllium husk ADD TO FORMULARY Non-Formulary Covered 05/24/2016 fiber therapy psyllium husk ADD TO FORMULARY Non-Formulary Covered 05/24/2016 reguloid psyllium husk ADD TO FORMULARY Non-Formulary Covered 05/24/2016 wal-mucil psyllium husk ADD TO FORMULARY Non-Formulary Covered 05/24/2016 METAMUCIL psyllium husk ADD TO FORMULARY Non-Formulary Covered 05/24/2016 daily fiber psyllium husk ADD TO FORMULARY Non-Formulary Covered 05/24/2016 medi-mucil psyllium husk ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 770 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 fiber laxative,fiber psyllium husk ADD TO FORMULARY Non-Formulary Covered 05/24/2016 natural fiber psyllium husk ADD TO FORMULARY Non-Formulary Covered 05/24/2016 natural psyllium fiber psyllium husk/aspartame ADD TO FORMULARY Non-Formulary Covered 05/24/2016 wal-mucil psyllium husk/aspartame ADD TO FORMULARY Non-Formulary Covered 05/24/2016 natural daily fiber psyllium husk/aspartame ADD TO FORMULARY Non-Formulary Covered 05/24/2016 geri-mucil psyllium husk/aspartame ADD TO FORMULARY Non-Formulary Covered 05/24/2016 natural fiber laxative psyllium husk/aspartame ADD TO FORMULARY Non-Formulary Covered 05/24/2016 fiber psyllium husk/aspartame ADD TO FORMULARY Non-Formulary Covered 05/24/2016 natural fiber supplement psyllium husk/aspartame ADD TO FORMULARY Non-Formulary Covered 05/24/2016 METAMUCIL MULTIHEALTH FIBER psyllium husk/aspartame ADD TO FORMULARY Non-Formulary Covered 05/24/2016 METAMUCIL,ME psyllium husk/aspartame TAMUCIL SUGAR-FREE ADD TO FORMULARY Non-Formulary Covered 05/24/2016 konsyl psyllium husk (with sugar) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 natural fiber laxative psyllium husk (with sugar) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 fiber psyllium husk (with sugar) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 wal-mucil natural psyllium husk (with sugar) fiber lax ADD TO FORMULARY Non-Formulary Covered 05/24/2016 natural vegetable psyllium husk (with sugar) powder ADD TO FORMULARY Non-Formulary Covered 05/24/2016 METAMUCIL psyllium husk (with sugar) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 fiber psyllium husk (with sugar) ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 771 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 konsyl psyllium husk (with sugar) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 daily fiber psyllium husk (with sugar) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 natural fiber laxative psyllium husk (with sugar) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 natural fiber psyllium seed ADD TO FORMULARY Non-Formulary Covered 05/24/2016 fiber therapy psyllium seed,psyllium husk/aspartame ADD TO FORMULARY Non-Formulary Covered 05/24/2016 natural fiber psyllium seed ADD TO FORMULARY Non-Formulary Covered 05/24/2016 natural fiber psyllium seed/aspartame ADD TO FORMULARY Non-Formulary Covered 05/24/2016 natural fiber powder psyllium seed (with sugar),psyllium seed (with dextrose) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 fiber smooth psyllium seed (with sugar) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 metamucil psyllium seed (with sugar) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 metamucil,metam psyllium seed (with ucil ot sugar),psyllium seed (with dextrose) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 reguloid psyllium seed (with sugar) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 fiber therapy psyllium seed (with sugar) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 fiber laxative psyllium seed (with sugar) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 fiber laxative psyllium husk (with sugar) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 natural fiber laxative,natural fiber psyllium husk (with sugar) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 METAMUCIL psyllium husk (with sugar) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 wal-mucil psyllium husk (with sugar) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 fiber psyllium husk (with sugar) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 natural daily fiber psyllium husk (with sugar) ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 772 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 fiber psyllium seed (with dextrose) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 natural vegetable psyllium seed (with powder dextrose) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 natural vegetable psyllium seed (with powder dextrose) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 KONSYL FORMULA-D ADD TO FORMULARY Non-Formulary Covered 05/24/2016 METAMUCIL,ME psyllium husk/aspartame TAMUCIL SUGAR FREE ADD TO FORMULARY Non-Formulary Covered 05/24/2016 KONSYL psyllium husk/aspartame ADD TO FORMULARY Non-Formulary Covered 05/24/2016 KONSYL EASY MIX psyllium husk ADD TO FORMULARY Non-Formulary Covered 05/24/2016 psyllium seed psyllium husk ADD TO FORMULARY Non-Formulary Covered 05/24/2016 KONSYL psyllium husk ADD TO FORMULARY Non-Formulary Covered 05/24/2016 METAMUCIL psyllium husk (with sugar) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 konsyl psyllium husk (with sugar) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 natural fiber supplement psyllium husk/aspartame ADD TO FORMULARY Non-Formulary Covered 05/24/2016 METAMUCIL psyllium husk/aspartame FIBER SINGLES ADD TO FORMULARY Non-Formulary Covered 05/24/2016 KONSYL psyllium husk/aspartame ADD TO FORMULARY Non-Formulary Covered 05/24/2016 KONSYL psyllium husk ADD TO FORMULARY Non-Formulary Covered 05/24/2016 METAMUCIL psyllium seed (with sugar) ADD TO FORMULARY Non-Formulary Covered 05/24/2016 best fiber wheat dextrin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 total fiber wheat dextrin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 BENEFIBER wheat dextrin ADD TO FORMULARY Non-Formulary Covered psyllium husk (with dextrose) BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 773 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 NUTRISOURCE guar gum FIBER ADD TO FORMULARY Non-Formulary Covered 05/24/2016 NUTRISOURCE guar gum FIBER ADD TO FORMULARY Non-Formulary Covered 05/24/2016 wal-mucil plus psyllium husk/calcium calcium,wal-mucil carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 METAMUCIL psyllium husk/calcium PLUS CALCIUM carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 easy fiber wheat dextrin/calcium carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 FIBER-STAT fructooligosaccharides/malto dextrin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 FIBER-STAT fructooligosaccharides/polyd extrose ADD TO FORMULARY Non-Formulary Covered 05/24/2016 COLOX psyllium husk/laxative combination no.1 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 HYFIBER,HYFIB fructooligosaccharides/polyd ER WITH FOS extrose ADD TO FORMULARY Non-Formulary Covered 05/24/2016 KONSYL BALANCE psyllium husk/inulin/aspartame ADD TO FORMULARY Non-Formulary Covered 05/24/2016 fiber with probiotic wheat dextrin/lactobacillus acidophilus/aspartame ADD TO FORMULARY Non-Formulary Covered 05/24/2016 KONDREMUL mineral oil/carrageenan ADD TO FORMULARY Non-Formulary Covered 05/24/2016 PEDIA-LAX magnesium hydroxide ADD TO FORMULARY Non-Formulary Covered 05/24/2016 milk of magnesia magnesium hydroxide ADD TO FORMULARY Non-Formulary Covered 05/24/2016 GLYCERIN LAXATIVE glycerin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 PEDIA-LAX glycerin ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 774 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 polyethylene glycol 3350 polyethylene glycol 3350 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 healthylax polyethylene glycol 3350 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 smoothlax polyethylene glycol 3350 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 miralax polyethylene glycol 3350 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 purelax polyethylene glycol 3350 ADD TO FORMULARY 05/24/2016 purelax polyethylene glycol 3350 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 MIRALAX polyethylene glycol 3350 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 smoothlax polyethylene glycol 3350 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 laxa clear polyethylene glycol 3350 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 gavilax polyethylene glycol 3350 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 powderlax polyethylene glycol 3350 ADD TO FORMULARY 05/24/2016 powderlax polyethylene glycol 3350 ADD TO FORMULARY 05/24/2016 laxative peg 3350 polyethylene glycol 3350 ADD TO FORMULARY 05/24/2016 laxative peg 3350 polyethylene glycol 3350 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 clearlax polyethylene glycol 3350 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 purelax polyethylene glycol 3350 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 gentlelax polyethylene glycol 3350 ADD TO FORMULARY 05/24/2016 gentlelax polyethylene glycol 3350 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 peg3350 polyethylene glycol 3350 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 polyethylene glycol 3350 polyethylene glycol 3350 ADD TO FORMULARY 05/24/2016 polyethylene polyethylene glycol 3350 glycol 3350,polyethylen e glycol ADD TO FORMULARY Non-Formulary Covered 05/24/2016 glycolax ADD TO FORMULARY Non-Formulary Covered polyethylene glycol 3350 Covered Covered Non-Formulary Covered Covered Covered Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 775 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 oral saline laxative sodium phosphate,monobasic/sodiu m phosphate,dibasic ADD TO FORMULARY Non-Formulary Covered 05/24/2016 phosphate laxative sodium phosphate,monobasic/sodiu m phosphate,dibasic ADD TO FORMULARY Non-Formulary Covered 05/24/2016 preparation cleansing sodium phosphate,monobasic/sodiu m phosphate,dibasic ADD TO FORMULARY Non-Formulary Covered 05/24/2016 oral saline sodium laxative,oral phosphate,monobasic/sodiu saline laxative kit m phosphate,dibasic ADD TO FORMULARY Non-Formulary Covered 05/24/2016 phosphate laxative sodium phosphate,monobasic/sodiu m phosphate,dibasic ADD TO FORMULARY Non-Formulary Covered 05/24/2016 enema disposable sodium phosphate,monobasic/sodiu m phosphate,dibasic ADD TO FORMULARY Non-Formulary Covered 05/24/2016 phosphate sodium enema,disposabl phosphate,monobasic/sodiu e enema m phosphate,dibasic ADD TO FORMULARY Non-Formulary Covered 05/24/2016 enema,saline enema sodium phosphate,monobasic/sodiu m phosphate,dibasic ADD TO FORMULARY Non-Formulary Covered 05/24/2016 curad enema sodium phosphate,monobasic/sodiu m phosphate,dibasic ADD TO FORMULARY Non-Formulary Covered 05/24/2016 FLEET sodium ENEMA,ENEMA phosphate,monobasic/sodiu m phosphate,dibasic ADD TO FORMULARY Non-Formulary Covered 05/24/2016 pure & gentle saline enema ADD TO FORMULARY Non-Formulary Covered sodium phosphate,monobasic/sodiu m phosphate,dibasic BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 776 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 enema sodium phosphate,monobasic/sodiu m phosphate,dibasic ADD TO FORMULARY Covered 05/24/2016 enema sodium phosphate,monobasic/sodiu m phosphate,dibasic ADD TO FORMULARY Non-Formulary Covered 05/24/2016 pediatric enema sodium phosphate,monobasic/sodiu m phosphate,dibasic ADD TO FORMULARY Non-Formulary Covered 05/24/2016 PEDIA-LAX ENEMA sodium phosphate,monobasic/sodiu m phosphate,dibasic ADD TO FORMULARY Non-Formulary Covered 05/24/2016 SUPREP sodium sulfate/potassium sulfate/magnesium sulfate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 NULYTELY WITH FLAVOR PACKS sodium chloride/sodium bicarbonate/potassium chloride/peg ADD TO FORMULARY Non-Formulary Covered 05/24/2016 peg 3350electrolyte,peg3350 with flavor packs sodium chloride/sodium bicarbonate/potassium chloride/peg ADD TO FORMULARY Non-Formulary Covered 05/24/2016 gavilyte-n sodium chloride/sodium bicarbonate/potassium chloride/peg ADD TO FORMULARY Non-Formulary Covered 05/24/2016 trilyte with flavor packets sodium chloride/sodium bicarbonate/potassium chloride/peg ADD TO FORMULARY Non-Formulary Covered 05/24/2016 peg-3350 with flavor packs sodium chloride/sodium bicarbonate/potassium chloride/peg ADD TO FORMULARY Non-Formulary Covered 05/24/2016 COLYTE WITH peg 3350/sod sulf/sod FLAVOR PACKS bicarbonate/sod chloride/potassium chl ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 777 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 peg-3350 and electrolytes peg 3350/sod sulf/sod bicarbonate/sod chloride/potassium chl ADD TO FORMULARY Non-Formulary Covered 05/24/2016 GOLYTELY peg 3350/sod sulf/sod bicarbonate/sod chloride/potassium chl ADD TO FORMULARY Non-Formulary Covered 05/24/2016 gavilyte-g peg 3350/sod sulf/sod bicarbonate/sod chloride/potassium chl ADD TO FORMULARY Non-Formulary Covered 05/24/2016 COLYTE WITH FLAVOR PACKETS peg 3350/sod sulf/sod bicarbonate/sod chloride/potassium chl ADD TO FORMULARY Non-Formulary Covered 05/24/2016 gavilyte-c peg 3350/sod sulf/sod bicarbonate/sod chloride/potassium chl ADD TO FORMULARY Non-Formulary Covered 05/24/2016 peg 3350electrolyte peg 3350/sod sulf/sod bicarbonate/sod chloride/potassium chl ADD TO FORMULARY Non-Formulary Covered 05/24/2016 GOLYTELY peg 3350/sod sulf/sod bicarbonate/sod chloride/potassium chl ADD TO FORMULARY Non-Formulary Covered 05/24/2016 MOVIPREP peg 3350/sodium sulfate/sod chloride/kcl/ascorbate sod/vit c ADD TO FORMULARY Non-Formulary Covered 05/24/2016 SUCLEAR polyethylene glycol 3350/bowel prep #2,two part prep ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ENEMA sodium phosphate,monobasic/sodiu m phosphate,dibasic ADD TO FORMULARY Non-Formulary Covered 05/24/2016 laxative,gentle laxative bisacodyl ADD TO FORMULARY Non-Formulary Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 778 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 woman's bisacodyl laxative,women's laxative ADD TO FORMULARY Non-Formulary Covered 05/24/2016 women's gentle laxative bisacodyl ADD TO FORMULARY Non-Formulary Covered 05/24/2016 DULCOLAX bisacodyl ADD TO FORMULARY Non-Formulary Covered 05/24/2016 women's laxative bisacodyl ADD TO FORMULARY Non-Formulary Covered 05/24/2016 bisacodyl bisacodyl ADD TO FORMULARY Non-Formulary Covered 05/24/2016 bisacodyl bisacodyl ADD TO FORMULARY Non-Formulary Covered 05/24/2016 bisa-lax bisacodyl ADD TO FORMULARY Non-Formulary Covered 05/24/2016 alophen pills bisacodyl ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ducodyl bisacodyl ADD TO FORMULARY Non-Formulary Covered 05/24/2016 gentle laxative bisacodyl ADD TO FORMULARY Non-Formulary Covered 05/24/2016 castor oil castor oil ADD TO FORMULARY 05/24/2016 castor oil castor oil ADD TO FORMULARY Non-Formulary Covered 05/24/2016 SENNA senna leaf extract ADD TO FORMULARY Non-Formulary Covered 05/24/2016 senna leaves senna leaf ADD TO FORMULARY Non-Formulary Covered 05/24/2016 NATURAL VEGETABLE LAXATIVE senna/fennel ADD TO FORMULARY Non-Formulary Covered 05/24/2016 SENNA PROMPT sennosides/psyllium husk ADD TO FORMULARY 05/24/2016 SENNA PROMPT sennosides/psyllium husk,sennosides/psyllium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 PREPOPIK sodium picosulfate/magnesium oxide/citric acid ADD TO FORMULARY Non-Formulary Covered Covered Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 779 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 peg-prep bisacodyl/sodium chlor/sodium bicarb/potassium chl/peg 3350 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 gavilyte-h and bisacodyl bisacodyl/sodium chlor/sodium bicarb/potassium chl/peg 3350 ADD TO FORMULARY Non-Formulary Covered 05/24/2016 medi-laxx sennosides/docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 senna laxative sennosides/docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 senna plus sennosides/docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 senna-time s sennosides/docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 stimulant laxative sennosides/docusate plus sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 stool softener sennosides/docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 SENNA S sennosides/docusate sodium ADD TO FORMULARY 05/24/2016 senna-s,senna s sennosides/docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 lax stool softener sennosides/docusate with senna sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 SENOKOT-S sennosides/docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 sennosidessennosides/docusate docusate sodium sodium,sennadocusate sodium ADD TO FORMULARY Non-Formulary Covered Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 780 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 senna-docusate sennosides/docusate sodium,docusate sodium sodium-senna ADD TO FORMULARY Non-Formulary Covered 05/24/2016 medi-natural senna stool soft sennosides/docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 PERI-COLACE sennosides/docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 dok plus sennosides/docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 SENNALAX-S sennosides/docusate sodium ADD TO FORMULARY 05/24/2016 sennalax-s sennosides/docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 senexon-s sennosides/docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 stool softenersennosides/docusate stimulant sodium lax,stool softener ADD TO FORMULARY Non-Formulary Covered 05/24/2016 laxacin sennosides/docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 p-col rite sennosides/docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 doc-q-lax sennosides/docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 stool softenerlaxative sennosides/docusate sodium ADD TO FORMULARY 05/24/2016 stool softenerlaxative,stool softener sennosides/docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ENEMEEZ docusate sodium/benzocaine ADD TO FORMULARY Non-Formulary Covered Covered Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 781 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 DOCUSOL PLUS docusate sodium/benzocaine ADD TO FORMULARY Covered 05/24/2016 DOCUSOL PLUS docusate sodium/benzocaine ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CEO-TWO potassium bitartrate/sodium bicarbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 PHOSLO calcium acetate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium acetate calcium acetate ADD TO FORMULARY 05/24/2016 calcium acetate calcium acetate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calphron calcium acetate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium acetate calcium acetate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 eliphos calcium acetate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 PHOSLYRA calcium acetate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 AURYXIA ferric citrate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 FOSRENOL lanthanum carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 FOSRENOL lanthanum carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 FOSRENOL lanthanum carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 FOSRENOL lanthanum carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 FOSRENOL lanthanum carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 sevelamer carbonate sevelamer carbonate ADD UM: AUTHORIZATION 05/24/2016 sevelamer carbonate sevelamer carbonate ADD TO FORMULARY 05/24/2016 RENVELA sevelamer carbonate ADD UM: AUTHORIZATION 05/24/2016 RENVELA sevelamer carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 RENVELA sevelamer carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 RENVELA sevelamer carbonate ADD UM: AUTHORIZATION Covered PA applies Non-Formulary Covered PA applies PA applies BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 782 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 RENVELA sevelamer carbonate ADD UM: AUTHORIZATION PA applies 05/24/2016 RENVELA sevelamer carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 RENAGEL sevelamer hcl ADD TO FORMULARY Non-Formulary Covered 05/24/2016 RENAGEL sevelamer hcl ADD TO FORMULARY 05/24/2016 RENAGEL sevelamer hcl ADD TO FORMULARY Non-Formulary Covered 05/24/2016 VELPHORO sucroferric oxyhydroxide ADD TO FORMULARY Non-Formulary Covered 05/24/2016 MAGNEBIND 300 calcium carbonate/magnesium carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 MAGNEBIND 400 RX calcium carbonate/magnesium carbonate/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 doxercalciferol doxercalciferol ADD TO FORMULARY 05/24/2016 doxercalciferol doxercalciferol ADD TO FORMULARY Non-Formulary Covered 05/24/2016 HECTOROL doxercalciferol ADD TO FORMULARY Non-Formulary Covered 05/24/2016 HECTOROL doxercalciferol ADD TO FORMULARY Non-Formulary Covered 05/24/2016 doxercalciferol doxercalciferol ADD TO FORMULARY Non-Formulary Covered 05/24/2016 doxercalciferol doxercalciferol ADD TO FORMULARY Non-Formulary Covered 05/24/2016 HECTOROL doxercalciferol ADD TO FORMULARY Non-Formulary Covered 05/24/2016 HECTOROL doxercalciferol ADD TO FORMULARY Non-Formulary Covered 05/24/2016 HECTOROL doxercalciferol ADD TO FORMULARY Non-Formulary Covered 05/24/2016 doxercalciferol doxercalciferol ADD TO FORMULARY Non-Formulary Covered 05/24/2016 paricalcitol paricalcitol ADD TO FORMULARY 05/24/2016 paricalcitol paricalcitol ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ZEMPLAR paricalcitol ADD TO FORMULARY Non-Formulary Covered 05/24/2016 paricalcitol paricalcitol ADD TO FORMULARY Covered Covered Covered Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 783 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 paricalcitol paricalcitol ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ZEMPLAR paricalcitol ADD TO FORMULARY Non-Formulary Covered 05/24/2016 paricalcitol paricalcitol ADD TO FORMULARY 05/24/2016 paricalcitol paricalcitol ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ZEMPLAR paricalcitol ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ZEMPLAR paricalcitol ADD TO FORMULARY Non-Formulary Covered 05/24/2016 paricalcitol paricalcitol ADD TO FORMULARY 05/24/2016 paricalcitol paricalcitol ADD TO FORMULARY 05/24/2016 paricalcitol paricalcitol ADD TO FORMULARY 05/24/2016 paricalcitol paricalcitol ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ZEMPLAR paricalcitol ADD TO FORMULARY Non-Formulary Covered 05/24/2016 medi-natural sennosides ADD TO FORMULARY Non-Formulary Covered 05/24/2016 senna lax sennosides ADD TO FORMULARY 05/24/2016 senna lax sennosides ADD TO FORMULARY 05/24/2016 senna sennosides ADD TO FORMULARY 05/24/2016 senna sennosides ADD TO FORMULARY Non-Formulary Covered 05/24/2016 senno sennosides ADD TO FORMULARY Non-Formulary Covered 05/24/2016 senna laxative sennosides ADD TO FORMULARY 05/24/2016 senna laxative sennosides ADD TO FORMULARY Non-Formulary Covered 05/24/2016 natural senna laxative sennosides ADD TO FORMULARY Non-Formulary Covered 05/24/2016 sen-o-tab sennosides ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vegetable laxative sennosides ADD TO FORMULARY Non-Formulary Covered 05/24/2016 natural vegetable sennosides laxative ADD TO FORMULARY Non-Formulary Covered Covered Covered Non-Formulary Covered Covered Covered Non-Formulary Covered Covered Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 784 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 evac-u-gen sennosides ADD TO FORMULARY Non-Formulary Covered 05/24/2016 geri-kot sennosides ADD TO FORMULARY Non-Formulary Covered 05/24/2016 laxative sennosides ADD TO FORMULARY Non-Formulary Covered 05/24/2016 laxative pills sennosides ADD TO FORMULARY Non-Formulary Covered 05/24/2016 medi-lax sennosides ADD TO FORMULARY Non-Formulary Covered 05/24/2016 iron ferrous sulfate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 iron supplement,iron ferrous sulfate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 iron,ferrous sulfate ferrous sulfate ADD TO FORMULARY 05/24/2016 ferrous sulfate ferrous sulfate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 iron ferrous sulfate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ferrous sulfate ferrous sulfate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 senna sennosides ADD TO FORMULARY Non-Formulary Covered 05/24/2016 STOOL SOFTENER docusate sodium ADD TO FORMULARY 05/24/2016 stool softener docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 DOK docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 docusate sodium docusate sodium ADD TO FORMULARY 05/24/2016 docusate sodium docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 col-rite docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 womens stool softener docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 stool softener docusate sodium ADD TO FORMULARY 05/24/2016 stool softener docusate sodium ADD TO FORMULARY 05/24/2016 docusate sodium docusate sodium ADD TO FORMULARY Covered Covered Covered Covered Non-Formulary Covered Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 785 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 docusate sodium docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 DOK docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 col-rite docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 stool softener docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 col-rite docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 docusate sodium docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 stool softener docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 stool softener docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 docusate sodium docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 DIOCTO docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 dioctyl docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 pedia-lax stool softener docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 docusate sodium docusate sodium ADD TO FORMULARY 05/24/2016 docusate sodium docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 dok docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 stool softener docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 move it along docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 KRISTALOSE lactulose ADD TO FORMULARY Non-Formulary Covered 05/24/2016 lactulose lactulose ADD TO FORMULARY Non-Formulary Covered 05/24/2016 docusol docusate sodium ADD TO FORMULARY 05/24/2016 docusol docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 KRISTALOSE lactulose ADD TO FORMULARY Non-Formulary Covered 05/24/2016 laxative sennosides ADD TO FORMULARY Non-Formulary Covered Covered Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 786 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value Non-Formulary Covered 05/24/2016 chocolated laxative sennosides ADD TO FORMULARY 05/24/2016 laxative sennosides ADD TO FORMULARY 05/24/2016 laxative sennosides ADD TO FORMULARY Non-Formulary Covered 05/24/2016 senna laxative sennosides ADD TO FORMULARY Non-Formulary Covered 05/24/2016 natural laxative sennosides ADD TO FORMULARY Non-Formulary Covered 05/24/2016 laxative pills,laxative sennosides ADD TO FORMULARY Non-Formulary Covered 05/24/2016 senna sennosides ADD TO FORMULARY Non-Formulary Covered 05/24/2016 slow release iron ferrous sulfate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 slow release iron ferrous sulfate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 laxative sennosides ADD TO FORMULARY Non-Formulary Covered 05/24/2016 senna-extra sennosides ADD TO FORMULARY Non-Formulary Covered 05/24/2016 REPLESTA cholecalciferol (vitamin d3) ADD TO FORMULARY 05/24/2016 slow release iron ferrous sulfate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ferrous sulfate ferrous sulfate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ENEMEEZ docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 lactulose lactulose ADD TO FORMULARY Non-Formulary Covered 05/24/2016 lactulose lactulose ADD TO FORMULARY Non-Formulary Covered 05/24/2016 DIALYVITE VITAMIN D3 MAX cholecalciferol (vitamin d3) ADD TO FORMULARY 05/24/2016 DOCUSOL KIDS docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ferrous sulfate ferrous sulfate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 high potency iron ferrous sulfate ADD TO FORMULARY Non-Formulary Covered Covered Covered Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 787 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 vitamin ergocalciferol (vitamin d2) d2,ergocalciferol (vitamin d2) ADD TO FORMULARY Covered 05/24/2016 vitamin d2,vitamin d ADD TO FORMULARY Covered 05/24/2016 ferrous ferrous sulfate sulfate,children's ferrous sulfate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 fer-iron ADD TO FORMULARY Non-Formulary Covered 05/24/2016 d3-50,vitamin d3 cholecalciferol (vitamin d3) ADD TO FORMULARY 05/24/2016 ferrous sulfate ferrous sulfate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 MYKIDZ IRON 10 ferrous sulfate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 hydralazine hcl hydralazine hcl ADD TO FORMULARY Non-Formulary Covered 05/24/2016 hydralazine hcl hydralazine hcl CHANGE UM: QUANTITY 3 / Day 3 / days 05/24/2016 hydralazine hcl hydralazine hcl ADD TO FORMULARY Covered 05/24/2016 hydralazine hcl hydralazine hcl ADD TO FORMULARY Covered 05/24/2016 hydralazine hcl hydralazine hcl ADD TO FORMULARY Covered 05/24/2016 minoxidil minoxidil ADD TO FORMULARY Non-Formulary Covered 05/24/2016 minoxidil minoxidil ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CORLOPAM fenoldopam mesylate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium,calcium carbonate calcium carbonate ADD TO FORMULARY 05/24/2016 calcium calcium carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 CALCI-MIX calcium carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium calcium carbonate carbonate,calciu m ADD TO FORMULARY Non-Formulary Covered ergocalciferol (vitamin d2) ferrous sulfate Covered Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 788 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 calcium calcium carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 oyster shell calcium calcium carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 natural calcium calcium carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 oyster shell calcium calcium carbonate ADD TO FORMULARY 05/24/2016 calcium carbonate calcium carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium chloride calcium chloride ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium chloride calcium chloride ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium citrate calcium citrate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium gluconate calcium gluconate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium lactate calcium lactate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 iron iron ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ferrous sulfate ferrous sulfate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ferrous gluconate ferrous gluconate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 iron ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ferrous fumarate ferrous fumarate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ferrocite ferrous fumarate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 FERRIMIN 150 ferrous fumarate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 INFED iron dextran complex ADD TO FORMULARY Non-Formulary Covered 05/24/2016 complete multivitamin with iron,hematinic,multivits wiron,hematinic ADD TO FORMULARY Non-Formulary Covered 05/24/2016 VITAFOL ferrous fumarate/calcium/vitamin e/folic acid/multivitamin ADD TO FORMULARY Non-Formulary Covered ferrous gluconate Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 789 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 myferon-150 forte iron polysaccharide complex/cyanocobalamin/fol ic acid,iron polysaccharides complex/cyanocobalamin/fol ic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 poly-iron 150 forte iron polysaccharide complex/cyanocobalamin/fol ic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 iferex 150 forte iron polysaccharide complex/cyanocobalamin/fol ic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ferrex 150 forte iron polysaccharide complex/cyanocobalamin/fol ic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 magnesium,mag magnesium oxide nesium oxide ADD TO FORMULARY Non-Formulary Covered 05/24/2016 magnesium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 magnesium magnesium oxide oxide,magnesium ADD TO FORMULARY Covered 05/24/2016 magnesium oxide magnesium oxide ADD TO FORMULARY Covered 05/24/2016 magnesium magnesium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 magnesium magnesium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 MAGINEX magnesium aspartate hcl ADD TO FORMULARY Non-Formulary Covered 05/24/2016 magnesium chloride magnesium chloride ADD TO FORMULARY Non-Formulary Covered 05/24/2016 magbid er magnesium l-lactate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 magnesium magnesium oxide ADD TO FORMULARY Non-Formulary Covered 05/24/2016 magnesium sulfate magnesium sulfate ADD TO FORMULARY Non-Formulary Covered magnesium BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 790 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 magnesium gluconate magnesium gluconate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 sodium phosphate sodium phos,m-basic-dbasic ADD TO FORMULARY Non-Formulary Covered 05/24/2016 triphrocaps vitamin b complex and vitamin c no.20/folic acid ADD TO FORMULARY 05/24/2016 renal caps vitamin b complex and vitamin c no.20/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 reno caps vitamin b complex and vitamin c no.20/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 virt-caps vitamin b complex and vitamin c no.20/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 mynephrocaps vitamin b complex and vitamin c no.20/folic acid ADD TO FORMULARY Non-Formulary Covered 05/24/2016 THEREMS-M multivit,th iron,other min,multivits,th w-fe,other min ADD TO FORMULARY Non-Formulary Covered 05/24/2016 one daily women's multivit with calcium, iron, and other minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 women's daily formula multivit with calcium, iron, and other minerals ADD TO FORMULARY Non-Formulary Covered 05/24/2016 folic acid-vit b6vit b12 cyanocobalamin/folic acid/pyridoxine ADD TO FORMULARY Non-Formulary Covered 05/24/2016 vitamin d3,vitamin d cholecalciferol (vitamin d3) REMOVE UM: CUSTOM 05/24/2016 vitamin d3,vitamin d cholecalciferol (vitamin d3) ADD TO FORMULARY Covered 05/24/2016 vitamin d3 cholecalciferol (vitamin d3) ADD TO FORMULARY Covered 05/24/2016 vitamin d3 cholecalciferol (vitamin d3) ADD TO FORMULARY Covered Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 791 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 vitamin d3,vitamin d cholecalciferol (vitamin d3) ADD TO FORMULARY Covered 05/24/2016 aluminum hydroxide aluminum hydroxide ADD TO FORMULARY 05/24/2016 sodium bicarbonate sodium bicarbonate ADD TO FORMULARY Covered 05/24/2016 sodium bicarbonate sodium bicarbonate ADD TO FORMULARY Covered 05/24/2016 children's soothe calcium carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ANTACID calcium carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ALCALAK calcium carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium antacid calcium carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 antacid calcium carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 antacid calcium carbonate ADD TO FORMULARY 05/24/2016 calcium carbonate calcium carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 antacid calcium carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 cal-gest calcium carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ultra strength antacid calcium carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium carbonate calcium carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 antacid ultra strength calcium carbonate ADD TO FORMULARY 05/24/2016 calcium antacid calcium carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium antacid calcium carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium antacid calcium carbonate ADD TO FORMULARY Non-Formulary Covered Non-Formulary Covered Covered Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 792 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 PHILLIPS' MILK OF MAGNESIA magnesium hydroxide ADD TO FORMULARY Non-Formulary Covered 05/24/2016 PHILLIPS' magnesium hydroxide ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ri-mag magaldrate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 fiber therapy methylcellulose ADD TO FORMULARY 05/24/2016 soluble fiber methylcellulose ADD TO FORMULARY Non-Formulary Covered 05/24/2016 fiber laxative,fiber methylcellulose ADD TO FORMULARY Non-Formulary Covered 05/24/2016 fiber laxative,fiber calcium polycarbophil lax ADD TO FORMULARY 05/24/2016 fiber tabs,fibertabs calcium polycarbophil ADD TO FORMULARY Non-Formulary Covered 05/24/2016 fiber-lax calcium polycarbophil ADD TO FORMULARY Non-Formulary Covered 05/24/2016 fiber therapy calcium polycarbophil ADD TO FORMULARY 05/24/2016 fiber calcium polycarbophil ADD TO FORMULARY Non-Formulary Covered 05/24/2016 konsyl fiber calcium polycarbophil ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium polycarbophil calcium polycarbophil ADD TO FORMULARY 05/24/2016 equalactin calcium polycarbophil ADD TO FORMULARY Non-Formulary Covered 05/24/2016 reguloid psyllium seed ADD TO FORMULARY Non-Formulary Covered 05/24/2016 fiber laxative psyllium seed ADD TO FORMULARY Non-Formulary Covered 05/24/2016 fiber smooth psyllium seed ADD TO FORMULARY Non-Formulary Covered 05/24/2016 natural vegetable psyllium seed powder ADD TO FORMULARY Non-Formulary Covered 05/24/2016 natural vegetable psyllium seed powder ADD TO FORMULARY Non-Formulary Covered 05/24/2016 fiber therapy ADD TO FORMULARY Non-Formulary Covered psyllium husk (with sugar),psyllium seed Covered Covered Covered Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 793 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 HYDROCIL INSTANT psyllium seed ADD TO FORMULARY Non-Formulary Covered 05/24/2016 mineral oil mineral oil ADD TO FORMULARY Non-Formulary Covered 05/24/2016 ready to use enema mineral oil ADD TO FORMULARY Non-Formulary Covered 05/24/2016 enema mineral oil ADD TO FORMULARY Non-Formulary Covered 05/24/2016 mineral oil mineral oil ADD TO FORMULARY 05/24/2016 mineral oil extra heavy mineral oil ADD TO FORMULARY Non-Formulary Covered 05/24/2016 mineral oil mineral oil ADD TO FORMULARY Non-Formulary Covered 05/24/2016 mineral oil mineral oil ADD TO FORMULARY Non-Formulary Covered 05/24/2016 milk of magnesia magnesium hydroxide ADD TO FORMULARY Non-Formulary Covered 05/24/2016 magnesium citrate magnesium citrate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 citrate of magnesia magnesium citrate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 epsom salt magnesium sulfate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 glycerin glycerin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 child suppository glycerin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 laxative suppository glycerin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 SANI-SUPP glycerin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 adult glycerin,glycerin glycerin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 suppository glycerin ADD TO FORMULARY Non-Formulary Covered 05/24/2016 SANI-SUPP glycerin ADD TO FORMULARY Non-Formulary Covered Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 794 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name sodium phosphate,m-basic m-hyd/sodium phosphate,dibasic Type of Change Previous Value New Value ADD TO FORMULARY Non-Formulary Covered 05/24/2016 OSMOPREP 05/24/2016 women's bisacodyl laxative,woman's laxative ADD TO FORMULARY Non-Formulary Covered 05/24/2016 women's laxative bisacodyl ADD TO FORMULARY Non-Formulary Covered 05/24/2016 gentle laxative,laxative bisacodyl ADD TO FORMULARY Non-Formulary Covered 05/24/2016 laxative feminine bisacodyl ADD TO FORMULARY Non-Formulary Covered 05/24/2016 bisacodyl bisacodyl ADD TO FORMULARY Non-Formulary Covered 05/24/2016 bisacodyl bisacodyl ADD TO FORMULARY Non-Formulary Covered 05/24/2016 gentle laxative bisacodyl ADD TO FORMULARY Non-Formulary Covered 05/24/2016 laxative suppository,fast relief laxative bisacodyl ADD TO FORMULARY Non-Formulary Covered 05/24/2016 bisac-evac bisacodyl ADD TO FORMULARY Non-Formulary Covered 05/24/2016 castor oil castor oil ADD TO FORMULARY Non-Formulary Covered 05/24/2016 castor oil castor oil ADD TO FORMULARY Non-Formulary Covered 05/24/2016 docusate calcium docusate calcium ADD TO FORMULARY 05/24/2016 stool softener docusate calcium ADD TO FORMULARY Non-Formulary Covered 05/24/2016 dialyvite 800 folic acid/vitamin b comp and c ADD TO FORMULARY Non-Formulary Covered 05/24/2016 full spectrum b folic acid/vitamin b comp and c ADD TO FORMULARY Non-Formulary Covered 05/24/2016 rena-vite folic acid/vitamin b comp and c,folic acid/vitamin b comp w-c ADD TO FORMULARY Non-Formulary Covered Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 795 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/24/2016 renal vitamin folic acid/vitamin b comp and c ADD TO FORMULARY Covered 05/24/2016 calcium antacid calcium carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 calcium carbonate calcium carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 antacid,calcium antacid calcium carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 antacid extra strength,antacid calcium carbonate ADD TO FORMULARY Covered 05/24/2016 smooth calcium carbonate antacid,smooth dissolving antacid ADD TO FORMULARY Covered 05/24/2016 antacid extra strength,antacid calcium carbonate ADD TO FORMULARY Covered 05/24/2016 flavor chews antacid calcium carbonate ADD TO FORMULARY Non-Formulary Covered 05/24/2016 silace docusate sodium ADD TO FORMULARY Non-Formulary Covered 05/26/2016 AMITIZA lubiprostone REMOVE FROM FORMULARY Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 796 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change 05/26/2016 ferrous sulfate,sodium bicarbonate,docu sate sodium,senna prompt,senna,vit amin d3,lactulose,vege table laxative,natural senna laxative,senna laxative,iron,mov e it along,slow fe,slow release iron,stool softener,docusoft s,chocolated laxative,vacuant,i ron supplement,senn a s,docusol kids,promolaxin,l axative,colrite,mykidz iron 10,doc-qlace,senna lax,colace clear,d3 dots,drisdol,uniease,sennosides, antacid,kristalose ,fiber laxative,calcium citrate +vit d3,laxative maximum strength,calcium, calcium 600-vit ferrous sulfate,sodium bicarbonate,docusate sodium,sennosides/psyllium husk,sennosides,cholecalcif erol (vitamin d3),lactulose,sennosides/do cusate sodium,ergocalciferol (vitamin d2),calcium carbonate,calcium polycarbophil,calcium citrate/cholecalciferol (vitamin d3),calcium carbonate/cholecalciferol (vitamin d3),magnesium oxide,pediatric multivitamins a,c,& d3 no.21,iron/c/b12/b6/e acet/folic acid/intrinsic factor/senna leaf,folic acid/vitamin b comp and c,multivitamin with minerals/folic acid/calcium carb/vit k1,calcium carbonate, gluconate/magnesium oxide, gluconate,sodium phosphate,monobasic/sodiu m phosphate,dibasic,docusate sodium/benzocaine,docusat e calcium,pediatric multivitamin no.20,cyanocobalamin/folic acid/pyridoxine,hydralazine hcl,methylcellulose,wheat dextrin,pediatric multivitamins a,c,& d3 no.21 with sodium fluoride,paricalcitol,vit b REMOVE UM: AGEQUANTITY Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 797 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name d3,magnesium oxide,vitamin d,trivitamin,iroplex,vitamin d2,natural laxative,bcomplex + c,stool softenerlaxative,dok,one daily women's 50+,womens stool softener,calcium magnesium,mag nesium,children's vitamin d,decara,calcium citrate-vitamin d3,sennagen,sen exon,diocto,enem a,perdiem,d32000,ferosul,doc usol,docusol plus,genasoft,cor rectol extra gentle,docusate calcium,constulos e,fer-in-sol,d-visol,poly-vita,renal vitamin,folbic,hyd ralazine hcl,bcomplex with vitamin c,exlax,citrucel,ex-lax maximum strength,sennaextra,benefiber,c hildren's iron,laxative complex 100 combo no.2,sevelamer hcl,calcium acetate,multivitamin/ferrous fumarate/folic acid,magnesium sulfate,biotin,calcium carbonate/magnesium carbonate,mineral oil,vitamin b complex and vitamin c no.20/folic acid,ferrous fumarate/ascorbic acid/b12if/folic acid,magnesium chloride,polyethylene glycol 3350,pediatric multivitamin a,c,and d3 no.21,calcium phosphate, tribasic/cholecalciferol (vitamin d3),fluoride/vitamins a,c,and d,doxercalciferol,sodium polystyrene sulfonate,magnesium hydroxide/aluminum hydroxide/simethicone,multi vitamin with minerals/folic acid/lycopene/lutein,multivita min & minerals/ferrous fumarate/fa/vit k/lycop/lut,iron,carbonyl/folic acid/multivitamin with minerals,castor oil,vitamin e (dl-alpha tocopheryl acetate) Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 798 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value pills,therad,dss,albafort,sen na soft,senokotxtra,s enokot,senokot to go,colace,high potency iron,sennalaxs,vitamins a,c,d & fluoride,oyster shell calcium-vit d3,oyster shell calcium,paricalcit ol,b-100 complex,renagel, calcium acetate,regutol,o ne daily plus iron,sennac,phillips' laxative,evac-ugen,enemeez,ma gnesium sulfate,calcium carbonate,gerikot,d3-50,antacid extra strength,woman's laxative-docusate sod,docu liquid,ergocalcifer ol (vitamin d2),biotin,masanti antacid,triplevitamin wfluoride,feosol,dia lyvite vitamin d3 max,dialyvite vitamin d,sennaBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 799 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value gen,mineral oil,triphrocaps,se n-o-tab,av-vite fb,fiber therapy,calcium citrate - vitamin d3,tricon,dulcolax stool softener,ferrousul ,docusil,senno,nu mag,polyethylene glycol 3350,trivita,d-vita,kids vitamin d3,caltrate gummy bites,calcium polycarbophil,pol y-vitamin,trivitamin,trivitaminfluoride,sennacon ,docuprene,diocty l,doxercalciferol,c alcium 500-vit d3,sodium polystyrene sulfonate,antacid ultra strength,silace,m ylanta,purelax,ant acid maximum strength,laxative peg 3350,natural vegetable laxative,pedia-lax stool softener,sofBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 800 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value lax,just d,trivitamin with fluoride,vitamins a,d,c & fluoride,medilax,smooth dissolving antacid,powderla x,adults 50+ multivitamin,medi natural,sunvite,la xativesenna,docu soft,active fe,calcium citratevitamin d,optimal d3,ferrotime,gentlelax,ca stor oil,feriron,replesta,avvite fb forte,senna concentrate,supe r vitamin b,children's ferrous sulfate,oyster shell calciumvitamin d,vitamin e 05/27/2016 PROZAC WEEKLY fluoxetine hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 STRATTERA atomoxetine hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 STRATTERA atomoxetine hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 801 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/27/2016 STRATTERA atomoxetine hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 SYMBYAX olanzapine/fluoxetine hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 SYMBYAX olanzapine/fluoxetine hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 SYMBYAX olanzapine/fluoxetine hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 SYMBYAX olanzapine/fluoxetine hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 SYMBYAX olanzapine/fluoxetine hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 CYMBALTA duloxetine hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 STRATTERA atomoxetine hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 STRATTERA atomoxetine hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 CYMBALTA duloxetine hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 STRATTERA atomoxetine hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 STRATTERA atomoxetine hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 CYMBALTA duloxetine hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 ZYPREXA olanzapine ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 ZYPREXA olanzapine ADD UM: CUSTOM Carveout Drug Bill MDCH FFS BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 802 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/27/2016 ZYPREXA olanzapine ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 ZYPREXA olanzapine ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 ZYPREXA olanzapine ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 ZYPREXA olanzapine ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 ZYPREXA ZYDIS olanzapine ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 ZYPREXA ZYDIS olanzapine ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 ZYPREXA ZYDIS olanzapine ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 ZYPREXA ZYDIS olanzapine ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 ZYPREXA olanzapine ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 ZYPREXA RELPREVV olanzapine pamoate ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 ZYPREXA RELPREVV olanzapine pamoate ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 ZYPREXA RELPREVV olanzapine pamoate ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 DAKLINZA daclatasvir dihydrochloride ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 DAKLINZA daclatasvir dihydrochloride ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 SPRYCEL dasatinib ADD UM: CUSTOM Carveout Drug Bill MDCH FFS BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 803 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/27/2016 SPRYCEL dasatinib ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 SPRYCEL dasatinib ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 SPRYCEL dasatinib ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 SPRYCEL dasatinib ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 SPRYCEL dasatinib ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 ZERIT stavudine ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 ZERIT stavudine ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 ZERIT stavudine ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 ZERIT stavudine ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 ZERIT stavudine ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 REYATAZ atazanavir sulfate ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 REYATAZ atazanavir sulfate ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 REYATAZ atazanavir sulfate ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 REYATAZ atazanavir sulfate ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 REYATAZ atazanavir sulfate ADD UM: CUSTOM Carveout Drug Bill MDCH FFS BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 804 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/27/2016 EVOTAZ atazanavir sulfate/cobicistat ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 KLONOPIN clonazepam ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 KLONOPIN clonazepam ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 COPEGUS ribavirin ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 KLONOPIN clonazepam ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 INVIRASE saquinavir mesylate ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 INVIRASE saquinavir mesylate ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 PEGASYS peginterferon alfa-2a ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 PEGASYS peginterferon alfa-2a ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 PEGASYS peginterferon alfa-2a ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 PEGASYS PROCLICK peginterferon alfa-2a ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 PEGASYS PROCLICK peginterferon alfa-2a ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 FUZEON enfuvirtide ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 FUZEON enfuvirtide ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 BELSOMRA suvorexant ADD UM: CUSTOM Carveout Drug Bill MDCH FFS BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 805 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/27/2016 BELSOMRA suvorexant ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 ISENTRESS raltegravir potassium ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 BELSOMRA suvorexant ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 BELSOMRA suvorexant ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 ISENTRESS raltegravir potassium ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 ISENTRESS raltegravir potassium ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 CRIXIVAN indinavir sulfate ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 CRIXIVAN indinavir sulfate ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 ZEPATIER elbasvir/grazoprevir ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 ISENTRESS raltegravir potassium ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 EFFEXOR XR venlafaxine hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 EFFEXOR XR venlafaxine hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 EFFEXOR XR venlafaxine hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 PRISTIQ ER desvenlafaxine succinate ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 PRISTIQ ER desvenlafaxine succinate ADD UM: CUSTOM Carveout Drug Bill MDCH FFS BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 806 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/27/2016 XANAX alprazolam ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 XANAX alprazolam ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 XANAX XR alprazolam ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 XANAX XR alprazolam ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 XANAX XR alprazolam ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 XANAX XR alprazolam ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 XANAX alprazolam ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 XANAX alprazolam ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 CYKLOKAPRON tranexamic acid ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 APLENZIN bupropion hbr ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 APLENZIN bupropion hbr ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 APLENZIN bupropion hbr ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 KOGENATE FS antihemophilic factor (fviii) recomb,full length (albfree),antihemophilic factor, hum rec ADD UM: CUSTOM Carveout Drug Bill MDCH FFS BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 807 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/27/2016 KOGENATE FS antihemophilic factor (fviii) recomb,full length (albfree),antihemophilic factor, hum rec ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 KOGENATE FS antihemophilic factor (fviii) recomb,full length (albfree),antihemophilic factor, hum rec ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 KOGENATE FS antihemophilic factor (fviii) recomb,full length (alb-free) ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 KOGENATE FS antihemophilic factor (fviii) recomb,full length (alb-free) ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 PAXIL paroxetine hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 PAXIL paroxetine hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 PAXIL paroxetine hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 PAXIL CR paroxetine hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 PAXIL CR paroxetine hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 BUTISOL SODIUM butabarbital sodium ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 BUTISOL SODIUM butabarbital sodium ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 BUTISOL SODIUM butabarbital sodium ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 FELBATOL felbamate ADD UM: CUSTOM Carveout Drug Bill MDCH FFS BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 808 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/27/2016 FELBATOL felbamate ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 FELBATOL felbamate ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 EDLUAR zolpidem tartrate ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 EDLUAR zolpidem tartrate ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 GEODON ziprasidone mesylate ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 GEODON ziprasidone hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 GEODON ziprasidone hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 GEODON ziprasidone hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 GEODON ziprasidone hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 ZOLOFT sertraline hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 ZOLOFT sertraline hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 ZOLOFT sertraline hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 ZOLOFT sertraline hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 REMERON mirtazapine ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 REMERON mirtazapine ADD UM: CUSTOM Carveout Drug Bill MDCH FFS BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 809 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/27/2016 REMERON mirtazapine ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 REMERON mirtazapine ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 REMERON mirtazapine ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 REMERON mirtazapine ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 SAPHRIS asenapine maleate ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 SAPHRIS asenapine maleate ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 SAPHRIS asenapine maleate ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 SAPHRIS asenapine maleate ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 MONONINE factor ix ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 MONOCLATE-P antihemophilic factor, human ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 MONOCLATE-P antihemophilic factor, human ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 ALBUMINAR-5 albumin human ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 ALBUMINAR-25 albumin human ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 HELIXATE FS antihemophilic factor (fviii) recomb,full length (albfree),antihemophilic factor viii, human recombinant ADD UM: CUSTOM Carveout Drug Bill MDCH FFS BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 810 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/27/2016 HELIXATE FS antihemophilic factor (fviii) recomb,full length (albfree),antihemophilic factor viii, human recombinant ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 HELIXATE FS antihemophilic factor (fviii) recomb,full length (albfree),antihemophilic factor viii, human recombinant ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 HELIXATE FS antihemophilic factor (fviii) recomb,full length (albfree),antihemophilic factor viii, human recombinant ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 HELIXATE FS antihemophilic factor (fviii) recomb,full length (alb-free) ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 lithium lithium carbonate carbonate,lithium carbonate er ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 lithium lithium carbonate carbonate,lithium carbonate er ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 citalopram hbr,citalopram citalopram hydrobromide ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 risperidone risperidone ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 zaleplon zaleplon ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 zaleplon zaleplon ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 zolpidem tartrate zolpidem tartrate ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 zolpidem tartrate zolpidem tartrate ADD UM: CUSTOM Carveout Drug Bill MDCH FFS BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 811 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/27/2016 oxcarbazepine oxcarbazepine ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 oxcarbazepine oxcarbazepine ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 oxcarbazepine oxcarbazepine ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 buprenorphine hcl buprenorphine hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 buprenorphine hcl buprenorphine hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 buprenorphinenaloxone buprenorphine hcl/naloxone hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 buprenorphinenaloxone buprenorphine hcl/naloxone hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 oxcarbazepine oxcarbazepine ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 protriptyline hcl protriptyline hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 protriptyline hcl protriptyline hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 quetiapine fumarate quetiapine fumarate ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 quetiapine fumarate quetiapine fumarate ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 quetiapine fumarate quetiapine fumarate ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 quetiapine fumarate quetiapine fumarate ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 levetiracetam levetiracetam ADD UM: CUSTOM Carveout Drug Bill MDCH FFS BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 812 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/27/2016 quetiapine fumarate quetiapine fumarate ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 quetiapine fumarate quetiapine fumarate ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 imipramine pamoate imipramine pamoate ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 imipramine pamoate imipramine pamoate ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 imipramine pamoate imipramine pamoate ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 imipramine pamoate imipramine pamoate ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 eszopiclone eszopiclone ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 eszopiclone eszopiclone ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 eszopiclone eszopiclone ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 disulfiram disulfiram ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 disulfiram disulfiram ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 nevirapine nevirapine ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 nevirapine nevirapine ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 lithium carbonate lithium carbonate ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 lithium carbonate lithium carbonate ADD UM: CUSTOM Carveout Drug Bill MDCH FFS BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 813 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/27/2016 lithium carbonate lithium carbonate ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 alprazolam intensol alprazolam ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 diazepam diazepam ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 diazepam diazepam ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 lithium,lithium citrate lithium citrate ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 lorazepam intensol lorazepam ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 lithium carbonate lithium carbonate ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 triazolam triazolam ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 triazolam triazolam ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 lithium citrate,lithium lithium citrate ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 SUSTIVA efavirenz ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 SUSTIVA efavirenz ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 SUSTIVA efavirenz ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 NORPRAMIN desipramine hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 NORPRAMIN desipramine hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 814 UPDATED 09/2016 McLaren Health Plan, MI Medicaid Common Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/27/2016 NORPRAMIN desipramine hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 NORPRAMIN desipramine hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 NORPRAMIN desipramine hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 NORPRAMIN desipramine hcl ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 haloperidol haloperidol lactate lactate,haloperido l ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 BOSULIF bosutinib ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 BOSULIF bosutinib ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 INLYTA axitinib ADD UM: CUSTOM Carveout Drug Bill MDCH FFS 05/27/2016 IN
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New drugs not reviewed by the Physicians Plus P&T Committee for placemen...
