Magellan Rx Formulary
Standard and Precision Formulary Updates

Effective January 2021

The Magellan Rx Management Pharmacy & Therapeutics Committee (P&T) and Value Assessment Committee (VAC) meet periodically to review the status of drugs on the formulary and determine updates that are needed due to newly approved products, changes in practice guidelines, updates in FDA approved labeling and/or changes in financial implications. The following is the list of determinations made through this review process for the Magellan Rx Standard and Precision commercial formularies.

 

New Drugs

REVIEW DATELABEL NAMEINDICATIONSSIMILAR PRODUCTS*CHANGE TYPEFORMULARY STATUSEFFECTIVE DATE
Jan-21CERIANNA 148-3,700 MBQ/ML VIALdiagnostic imagingNEW BRANDNFJan-21
Jan-21GA 68 PSMA-11 18.5-185 MBQ/MLdiagnostic imagingNEW GENERICNFJan-21
Jan-21EPHEDRINE 15 MG/3 ML-0.9% NACLPressor agent used for allergic disordersEPHEDRINE SULFATENEW GENERICNFJan-21
Jan-21PHENYLEPHRINE 300 MG/250 ML-NSAlpha-1 adrenergic receptor agonist indicated for increasing blood pressureEMERPHED,
EPHEDRINE SULFATE
NEW GENERICNFJan-21
Jan-21NOREPINEPH 32 MG/250-0.9% NACLBlood pressure control in acute hypotensive statesNEW GENERICNFJan-21
Jan-21AVEIDAOXIA 1%-1%-4% GELCompounded product-Not FDA approvedIVERMECTIN-METRONIDAZOLE-NIACNNEW BRANDNFJan-21
Jan-21CHLOOXIA 0.05%-4% CREAMCompounded product-Not FDA approvedCLOBETASOL PROPION-NIACINAMIDENEW BRANDNFJan-21
Jan-21CHLOOXIA 0.05%-4% OINTMENTCompounded product-Not FDA approvedCLOBETASOL PROPION-NIACINAMIDENEW BRANDNFJan-21
Jan-21CHLOOXIA 0.05%-4% SOLUTIONCompounded product-Not FDA approvedCLOBETASOL PROPION-NIACINAMIDENEW BRANDNFJan-21
Jan-21DEOXIA 1%-4% GELCompounded product-Not FDA approvedCLINDAMYCIN-NIACINAMIDENEW BRANDNFJan-21
Jan-21DEOXIA 1%-4% LOTIONCompounded product-Not FDA approvedCLINDAMYCIN-NIACINAMIDENEW BRANDNFJan-21
Jan-21DIADIMAXIA 6%-2%-5% GELCompounded product-Not FDA approvedDAPSONE-NIACINAM-SPIRONOLACTONNEW BRANDNFJan-21
Jan-21DIAOXIA 6%-4% GELCompounded product-Not FDA approvedDAPSONE-NIACINAMIDENEW BRANDNFJan-21
Jan-21DIASDIMAXIA 8.5%-2%-5% GELCompounded product-Not FDA approvedDAPSONE-NIACINAM-SPIRONOLACTONNEW BRANDNFJan-21
Jan-21DIASOXIA 8.5%-4% GELCompounded product-Not FDA approvedDAPSONE-NIACINAMIDENEW BRANDNFJan-21
Jan-21DIFMETIOXRIME 4%-2%-1%-4% SOLNCompounded product-Not FDA approvedFLUCONAZ-IBU-ITRACONAZ-TERBINANEW BRANDNFJan-21
Jan-21DIMOXIA 4%-5% GELCompounded product-Not FDA approvedNIACINAMIDE-SPIRONOLACTONENEW BRANDNFJan-21
Jan-21DRAXACE 2%-8% SUSPENSIONCompounded product-Not FDA approvedSALICYLIC ACID-SULFACETAMIDENEW BRANDNFJan-21
Jan-21DRIXECE 5%-10% SUSPENSIONTopical suspensionSALICYLIC ACID-SULFACETAMIDENEW BRANDNFJan-21
Jan-21ECEOXIA 4%-10% CREAMCompounded product-Not FDA approvedNIACINAMIDE-SULFACETAMIDE SODNEW BRANDNFJan-21
Jan-21ETHOXIA 4%-0.05% CREAMCompounded product-Not FDA approvedNIACINAMIDE-TAZAROTENENEW BRANDNFJan-21
Jan-21HYLAZINC TABLETmineral deficiency,mineral deficiency prevention,vitamin deficiency,vitamin deficiency preventionFOLIKA-V,FOLITENEW BRANDNFJan-21
Jan-21IMIOXIA 1%-4% CREAMCompounded product-Not FDA approvedECONAZOLE NITRATE-NIACINAMIDENEW BRANDNFJan-21
Jan-21ITHOXIA 4%-0.1% CREAMCompounded product-Not FDA approvedNIACINAMIDE-TAZAROTENENEW BRANDNFJan-21
Jan-21KATARYA 0.5%-4%-0.025% EMULSCompounded product-Not FDA approvedHYDROCORT-HYDROQUINONE-TRETIN,KATARYAXNNEW BRANDNFJan-21
Jan-21KATARYAXN 0.5%-4%-0.025% EMULSCompounded product-Not FDA approvedHYDROCORT-HYDROQUINONE-TRETIN,KATARYANEW BRANDNFJan-21
Jan-21KAXM 4% EMULSIONCompounded product-Not FDA approvedHYDROQUINONENEW BRANDNFJan-21
Jan-21KEIDO 6% EMULSIONCompounded product-Not FDA approvedHYALURONIC ACID-HYDROQUINONENEW BRANDNFJan-21
Jan-21KETARYA 0.5%-6%-0.025% EMULSCompounded product-Not FDA approvedHYDROCORT-HYDROQUINONE-TRETINNEW BRANDNFJan-21
Jan-21KEVARYA 0.5%-6%-0.05% EMULSIONCompounded product-Not FDA approvedHYDROCORT-HYDROQUINONE-TRETINNEW BRANDNFJan-21
Jan-21KEXM 6% EMULSIONCompounded product-Not FDA approvedHYDROQUINONENEW BRANDNFJan-21
Jan-21KEYA 0.5%-6% EMULSIONCompounded product-Not FDA approvedHYDROCORTISONE-HYDROQUINONENEW BRANDNFJan-21
Jan-21KUTARYAXM 0.5%-8%-0.025% EMULSCompounded product-Not FDA approvedHYDROCORT-HYDROQUINONE-TRETIN,KUTARYAXMPANEW BRANDNFJan-21
Jan-21KUTARYAXMPA 0.5%-8%-0.025%Compounded product-Not FDA approvedHYDROCORT-HYDROQUINONE-TRETIN,KUTARYAXMNEW BRANDNFJan-21
Jan-21KUTEA 8% EMULSIONCompounded product-Not FDA approvedHYDROQUINONE,KUXMNEW BRANDNFJan-21
Jan-21KUVARYA 0.5%-8%-0.05% EMULSIONCompounded product-Not FDA approvedHYDROCORT-HYDROQUINONE-TRETINNEW BRANDNFJan-21
Jan-21KUVARYE 1%-8%-0.05% EMULSIONCompounded product-Not FDA approvedHYDROCORT-HYDROQUINONE-TRETINNEW BRANDNFJan-21
Jan-21KUXM 8% EMULSIONCompounded product-Not FDA approvedHYDROQUINONE,KUTEANEW BRANDNFJan-21
Jan-21PHEODOYO 2.5%-1%-2% CREAMCompounded product-Not FDA approvedHYDROCORT-IODOQUINOL-KETOCONAZNEW BRANDNFJan-21
Jan-21PHEYO 2.5%-2% CREAMCompounded product-Not FDA approvedHYDROCORTISONE-KETOCONAZOLENEW BRANDNFJan-21
Jan-21SZOSIL 3.6 CM X 15CM GEL SHEETCompounded product-Not FDA approvedSILICONE SCAR THERAPY GEL STRPNEW BRANDNFJan-21
Jan-21TARDEOXIA 1%-4%-0.025% CREAMCompounded product-Not FDA approvedCLINDAMY-NIACINAMIDE-TRETINOINNEW BRANDNFJan-21
Jan-21TARDIMAXIA 2%-5%-0.025% GELCompounded product-Not FDA approvedNIACINAM-SPIRONOLACT-TRETINOINNEW BRANDNFJan-21
Jan-21TAROXIA 4%-0.025% CREAMCompounded product-Not FDA approvedNIACINAMIDE-TRETINOINNEW BRANDNFJan-21
Jan-21TAROXIA 4%-0.025% GELCompounded product-Not FDA approvedNIACINAMIDE-TRETINOINNEW GENERICNFJan-21
Jan-21VARDIMAXIA 2%-5%-0.05% GELCompounded product-Not FDA approvedNIACINAM-SPIRONOLACT-TRETINOINNEW BRANDNFJan-21
Jan-21VAROXIA 4%-0.05% CREAMCompounded product-Not FDA approvedNIACINAMIDE-TRETINOINNEW BRANDNFJan-21
Jan-21VAROXIA 4%-0.05% GELCompounded product-Not FDA approvedNIACINAMIDE-TRETINOINNEW BRANDNFJan-21
Jan-21WESTGEL DHA SOFTGELlactating mother,pregnancyTRISTART DHANEW BRANDNFJan-21
Jan-21LIFEMS NALOXONE 2 MG/2 ML KITopiate-induced respiratory depression,opioid overdoseEVZIO,NALOXONE HCL,NARCANNEW BRANDNFJan-21
Jan-21ACETAMINOPHEN 1000MG/100ML BAGfever,pain,pain treatment adjunct,postoperative acute painTYLENOLNEW GENERICGENJan-21
Jan-21ACETAMINOPHEN 1000MG/100ML VLfever,pain,pain treatment adjunct,postoperative acute painOFIRMEVNEW GENERICGENJan-21
Jan-21ALVIMOPAN 12 MG CAPSULEpostoperative ileusENTEREGNEW GENERICGENJan-21
Jan-21XARACOLL 100 MG IMPLANTacute post-op pain following open inguinal hernia repairBUPIVACAINE NEW BRANDNPBJan-21
Jan-21MELOXICAM 10 MG CAPSULEosteoarthritisVIVLODEXNEW GENERICGENJan-21
Jan-21MELOXICAM 5 MG CAPSULEosteoarthritisVIVLODEXNEW GENERICGENJan-21
Jan-21NYMYO 0.25-0.035 MG (28) TABacne vulgaris,pregnancy contraceptionORTHO-CYCLEN, PREVIFEM,
SPRINTEC
NEW GENERICGENJan-21
Jan-21ICLEVIA 0.15 MG-0.03 MG TABLETpregnancy contraceptionINTROVALE,JOLESSANEW GENERICGENJan-21
Jan-21NITAZOXANIDE 500 MG TABLETgiardiasis,infection by CryptosporidiumALINIANEW GENERICGENJan-21
Jan-21VAXELIS VACCINE SYRINGEDPT, hepatitis B and polio vaccination,Haemophilus influenzae type b vaccinationTDAPNEW BRANDPBJan-21
Jan-21VAXELIS VACCINE VIALDPT, hepatitis B and polio vaccination,Haemophilus influenzae type b vaccinationTDAPNEW BRANDPBJan-21
Jan-21DIFICID 40 MG/ML SUSPENSIONClostridioides difficile infectionAZITHROMYCIN, ERYTHROMYCINNEW FORMULATIONNPBJan-21
Jan-21HYCODAN 5 MG-1.5 MG/5 ML SOLNcoughHYDROCODONE-HOMATROPINE MBR,
HYDROMET
NEW BRANDNPBJan-21
Jan-21RETACRIT 20,000 UNIT/ML VIALanemia due to chemotherapy and radiotherapy combination,anemia in chronic kidney disease,chemotherapy-induced anemia,reduction of allogeneic blood transfusion in surgery,zidovudine-induced anemiaARANESP,EPOGEN,MIRCERA,PROCRITNEW STRENGTHPSJan-21
Jan-21OXYTOCIN ACETATE POWDERbulk powder for compoundingNEW GENERICNPBJan-21
Jan-21IVERMECTIN 0.5% LOTIONpediculosis capitis,pediculosis preventionSKLICENEW GENERICGENJan-21
Jan-21DANYELZA 40 MG/10 ML VIALhigh-risk neuroblastoma in bone or bone marrowUNITUXINNEW BRANDNPSJan-21
Jan-21ORLADEYO 110 MG CAPSULEprevention of angioedema attack in hereditary angioedemaKALBITOR,TAKHZYRONEW BRANDNPSJan-21
Jan-21ORLADEYO 150 MG CAPSULEprevention of angioedema attack in hereditary angioedemaKALBITOR,TAKHZYRONEW BRANDNPSJan-21
Jan-21OXLUMO 94.5 MG/0.5 ML VIALprimary hyperoxaluria type INEW BRANDNFJan-21
Jan-21TRETINOIN GEL MICRO 0.1% PUMPacne vulgarisRETIN-A MICRO PUMPDRUG CHANGESNPBJan-21
Jan-21LEVOTHYROXINE 13 MCG CAPSULEadjunct to surgery or radiotherapy for thyroid carcinoma,hypothyroidismTIROSINTDRUG CHANGESNFJan-21
Jan-21LEVOTHYROXINE 25 MCG CAPSULEadjunct to surgery or radiotherapy for thyroid carcinoma,hypothyroidismTIROSINTDRUG CHANGESNFJan-21
Jan-21LEVOTHYROXINE 50 MCG CAPSULEadjunct to surgery or radiotherapy for thyroid carcinoma,hypothyroidismTIROSINTDRUG CHANGESNFJan-21
Jan-21LEVOTHYROXINE 75 MCG CAPSULEadjunct to surgery or radiotherapy for thyroid carcinoma,hypothyroidismTIROSINTDRUG CHANGESNFJan-21
Jan-21LEVOTHYROXINE 88 MCG CAPSULEadjunct to surgery or radiotherapy for thyroid carcinoma,hypothyroidismTIROSINTDRUG CHANGESNFJan-21
Jan-21LEVOTHYROXINE 100 MCG CAPSULEadjunct to surgery or radiotherapy for thyroid carcinoma,hypothyroidismTIROSINTDRUG CHANGESNFJan-21
Jan-21LEVOTHYROXINE 112 MCG CAPSULEadjunct to surgery or radiotherapy for thyroid carcinoma,hypothyroidismTIROSINTDRUG CHANGESNFJan-21
Jan-21LEVOTHYROXINE 125 MCG CAPSULEadjunct to surgery or radiotherapy for thyroid carcinoma,hypothyroidismTIROSINTDRUG CHANGESNFJan-21
Jan-21LEVOTHYROXINE 137 MCG CAPSULEadjunct to surgery or radiotherapy for thyroid carcinoma,hypothyroidismTIROSINTDRUG CHANGESNFJan-21
Jan-21LEVOTHYROXINE 150 MCG CAPSULEadjunct to surgery or radiotherapy for thyroid carcinoma,hypothyroidismTIROSINTDRUG CHANGESNFJan-21
Jan-21LEVOTHYROXINE 175 MCG CAPSULEadjunct to surgery or radiotherapy for thyroid carcinoma,hypothyroidismTIROSINTDRUG CHANGESNFJan-21
Jan-21LEVOTHYROXINE 200 MCG CAPSULEadjunct to surgery or radiotherapy for thyroid carcinoma,hypothyroidismTIROSINTDRUG CHANGESNFJan-21

Value Assessment Committee Highlights

REVIEW DATELABEL NAMEINDICATIONSSIMILAR PRODUCTS*CHANGE TYPEFORMULARY STATUSEFFECTIVE DATE
Jan-21AVSOLA 100 MG VIALCrohn's disease,ankylosing spondylitis,moderate to severe plaque psoriasis,psoriatic arthritis,rheumatoid arthritis,ulcerative colitisREMICADE, RENFLEXIS, INFLECTRADRUG CHANGESNF-->PSJan-21
Jan-21RENFLEXIS 100 MG VIALCrohn's disease,ankylosing spondylitis,moderate to severe plaque psoriasis,psoriatic arthritis,rheumatoid arthritis,ulcerative colitisREMICADE, INFLECTRA, AVSOLADRUG CHANGESPS --> NFJan-21
Jan-21UDENYCA 6 MG/0.6 ML SYRINGEprevention of neutropenia from cancer chemotherapyNEULTASTA, NEULASTA ONPRODRUG CHANGESNPS-->PSJan-21
Jan-21NEULASTA 6 MG/0.6 ML SYRINGEhematopoietic syndrome of acute radiation syndrome,prevention of neutropenia from cancer chemotherapyNEULASTA ONPRODRUG CHANGESNPS-->PSJan-21
Jan-21NEULASTA ONPRO 6 MG/0.6 ML KIThematopoietic syndrome of acute radiation syndrome,prevention of neutropenia from cancer chemotherapyNEULASTA, UDENYCADRUG CHANGESNPS-->PSJan-21
Jan-21ABIRATERONE 500 MG TABLETmetastatic castration-resistant prostate cancer,metastatic castration-sensitive prostate cancerZYTIGANEW GENERICNFJan-21
Jan-21ASENAPINE 10 MG TABLET SLmania associated with bipolar disorder,mixed bipolar I disorder,schizophreniaSAPHRISNEW GENERICNFJan-21
Jan-21ASENAPINE 2.5 MG TABLET SLmania associated with bipolar disorder,mixed bipolar I disorder,schizophreniaSAPHRISNEW GENERICNFJan-21
Jan-21ASENAPINE 5 MG TABLET SLmania associated with bipolar disorder,mixed bipolar I disorder,schizophreniaSAPHRISNEW GENERICNFJan-21
Jan-21ORTIKOS ER 6 MG CAPSULECrohn's diseaseBUDESONIDE ECDRUG CHANGESNFJan-21
Jan-21ORTIKOS ER 9 MG CAPSULECrohn's diseaseBUDESONIDE ECDRUG CHANGESNFJan-21
Jan-21TWIRLA 120-30 MCG/DAY PATCHpregnancy contraceptionLEVONEST,LEVONORGESTREL-ETHDRUG CHANGESNPB-->NFJan-21
Jan-21ARAZLO 0.045% LOTIONacne vulgarisFABIOR,TAZAROTENE,TAZORACDRUG CHANGESNFJan-21
Jan-21FABIOR 0.1% FOAMacne vulgaris,psoriasisARAZLO,TAZAROTENE,TAZORACDRUG CHANGESNPB-->NFJan-21
Jan-21PHEXXI 1.8-1-0.4% VAGINAL GELpregnancy contraceptionOTC SPERMICIDEDRUG CHANGESNPB-->NFJan-21
Jan-21TAZORAC 0.05% CREAMpsoriasisARAZLO,FABIOR,TAZAROTENEDRUG CHANGESNPB-->NFJan-21
Jan-21TAZORAC 0.05% GELpsoriasisARAZLO,FABIOR,TAZAROTENEDRUG CHANGESNPB-->NFJan-21
Jan-21TAZORAC 0.1% GELacne vulgaris,psoriasisARAZLO,FABIOR,TAZAROTENEDRUG CHANGES NPB-->NFJan-21