Effective March 6, 2017, the following newly marketed drugs have been added to the MassHealth Drug List.

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1 1. Additions Effective March 6, 2017, the following newly marketed drugs have been added to the MassHealth Drug List. Adlyxin (lixisenatide) PA Basaglar (insulin glargine 100 units/ml prefilled syringe) PA Bromsite (bromfenac 0.075%) PA Inflectra (infliximab-dyyb) PA Lartruvo (olaratumab) PA Rayaldee (calcifediol) PA Soliqua (insulin glargine/lixisenatide) PA Sustol (granisetron extended-release injection) PA > 2 units/ 28 days Vemlidy (tenofovir alafenamide) PA Xultophy (insulin degludec/liraglutide) PA Yosprala (aspirin/omeprazole) PA Zinplava (bezlotoxumab) PA 2. New FDA A -Rated Generics Effective March 6, 2017, the following FDA A -rated generic drugs have been added to the MassHealth Drug List. The brand name is listed with a # symbol, to indicate that prior authorization is required for the brand. New FDA A -Rated Generic Drug Generic Equivalent of aprepitant 40 mg and 125 mg capsule PA > Emend # 2 capsules/28 days aprepitant 80 mg PA > 4 capsules/28 days Emend # aprepitant trifold pack PA > 2 packs/28 days Emend # doripenem Doribax # methylphenidate extended-release PA < 3 years Concerta # and PA > 60 units/month 3. Change in Prior Authorization Status a. Effective March 6, 2017, the following vitamin D analog agents will require prior authorization. Hectorol (doxercalciferol capsule) PA Zemplar (paricalcitol capsule) PA b. Effective March 6, 2017, the following vitamin D analog agents will be restricted to the health care professional who administers the drug. MassHealth will not pay for these drugs to be dispensed through a retail pharmacy. Hectorol (doxercalciferol injection)^ Zemplar (paricalcitol injection)^ c. Effective March 6, 2017, the following smoking cessation agents will no longer require prior authorization. Nicotrol Inhaler (nicotine inhalation system) Nicotrol NS (nicotine nasal spray)

2 d. Effective March 6, 2017, the following smoking cessation agent will no longer require prior authorization for exceeding duration of therapy limits. Chantix (varenicline) e. Effective March 6, 2017, the following scabicide agent will require prior authorization. Eurax (crotamiton) PA 4. New or Revised Therapeutic Tables Table 6 has been updated from Smoking Cessation to Vitamins and Vitamin Analogs. Table 3 Gastrointestinal Drugs - Histamine H2 Antagonists, Proton Pump Inhibitors Table 4 Hematologic Agents - Hematopoietic Agents Table 5 Immunological Agents Table 6 Vitamins and Vitamin Analogs Table 10 Dermatologic Agents Acne and Rosacea Table 13 Lipid Lowering Agents Table 18 Cardiovascular Agents Table 20 Anticonvulsants Table 22 Hormones - Somatostatin Analogues and Acromegaly Agents Table 24 Antipsychotics Table 27 Antiemetics Table 28 Antifungal Agents - Topical Table 29 Anti-allergy and Anti-inflammatory Agents Ophthalmic Table 31 Cerebral Stimulants and Miscellaneous Agents Table 35 Antibiotics - Oral Table 38 Antiretroviral/HIV Therapy Table 39 Neuraminidase Inhibitors Table 41 Antibiotics - Topical Table 44 Hepatitis Antiviral Agents Table 45 Antidiabetic Agents - Injectable and Insulin Table 48 Antiparkinsonian Agents Table 54 Pediculicides and Scabicides Table 57 Oncology Agents Table 58 Anticoagulants and Antiplatelet Agents Table 61 Gastrointestinal Drugs - Antidiarrheals, Antispasmodics, Bile Acid Agents, Bowel Preparation, and Constipation Agents Table 66 Antibiotics Injectable 5. Updated and New Prior-Authorization Request Forms Anticoagulant and Antiplatelet Prior Authorization Request Antidiabetic Agents Prior Authorization Request Antiemetics Prior Authorization Request Antipsychotic Prior Authorization Request Antiretroviral Agents Prior Authorization Request Constipation Agents Prior Authorization Request Erythropoiesis-Stimulating Agents Prior Authorization Request General Drug Prior Authorization Request Glaucoma Agents Prior Authorization Request

3 Hepatitis Antiviral Agents Prior Authorization Request Immunomodulators Prior Authorization Request Injectable Antibiotic Prior Authorization Request Lipid Lowering Agent Prior Authorization Request Ophthalmic Anti-Allergy and Anti-Inflammatory Agents Prior Authorization Request Opioid Dependence and Reversal Agents Prior Authorization Request Oral Antibiotic Prior Authorization Request Pediculicides and Scabicides Prior Authorization Request Prostate Cancer Agents Prior Authorization Request Proton Pump Inhibitor Prior Authorization Request Topical Vitamin D Analogues Prior Authorization Request 6. MassHealth Brand Name Preferred Over Generic Drug List a. Effective March 6, 2017, the following anti-acne dermatological agents will be added to the MassHealth Brand Name Preferred Over Generic Drug List. Differin (adapalene) BP PA Retin-A (tretinoin) BP PA 22 years b. Effective March 6, 2017, the following inhaled respiratory agents will be added to the MassHealth Brand Name Preferred Over Generic Drug List. Advair (fluticasone/salmeterol) BP PA Proair HFA (albuterol inhaler) BP c. Effective March 6, 2017, the following lipid lowering agent will be added to the MassHealth Brand Name Preferred Over Generic Drug List. Vytorin (ezetimibe/simvastatin) BP PA d. Effective March 6, 2017, the following antidepressant agent will be added to the MassHealth Brand Name Preferred Over Generic Drug List. Pristiq (desvenlafaxine succinate extended-release) BP PA e. Effective March 6, 2017, the following Attention-Deficit/Hyperactivity Disorder agent will be added to the MassHealth Brand Name Preferred Over Generic Drug List. Strattera (atomoxetine) BP PA < 6 years 7. Updated MassHealth Quick Reference Guide The MassHealth Quick Reference Guide has been updated to reflect recent changes to the MassHealth Drug List. 8. Deletions a. The following drugs have been removed from the MassHealth Drug List because they have been discontinued by the manufacturer. Akne-Mycin (erythromycin ointment) PA Desquam (benzoyl peroxide) PA

4 Elspar (asparaginase) ^ lindane lotion PA Nuox (benzoyl peroxide/sulfur) PA Zoderm (benzoyl peroxide/urea) PA b. The following drugs have been removed from the MassHealth Drug List. MassHealth does not pay for drugs that are manufactured by companies that have not signed rebate agreements with the U.S. Secretary of Health and Human Services. Benzefoam (benzoyl peroxide 5.3% foam) PA Benzefoam Ultra (benzoyl peroxide 9.8% foam) PA Clindagel (clindamycin gel) PA Inova (benzoyl peroxide/vitamin E pad) PA Pacnex Cleansing Pads (benzoyl peroxide) PA Ulesfia (benzyl alcohol lotion) PA 9. Corrections / Clarifications a. The following drugs have been added to the MassHealth Drug List. They were omitted in error. These changes do not reflect any change in MassHealth Policy. Benzepro (benzoyl peroxide 7% microspheres) PA Benzepro (benzoyl peroxide foaming cloth) PA Erygel # (erythromycin gel) PA 22 years esomeprazole strontium PA gentamicin topical cream, ointment methylcellulose * Ortho Micronor # (norethindrone) Zantac # (ranitidine injection) b. The following listings have been clarified. These changes do not reflect any change in MassHealth Policy. aspirin with buffers * Epaned (enalapril solution) PA Hyperhep B (hepatitis B immune globulin IM, human) Hyperrab (rabies immune globulin IM, human) Hyperrho (rho(d) immune globulin IM, human) Loprox # (ciclopirox 0.77% cream, suspension) Nexium (esomeprazole magnesium) PA Prevacid # (lansoprazole capsule) PA 2 years Prevacid Solutab (lansoprazole orally disintegrating tablet) PA 2 years sennosides * Viread (tenofovir disoproxil fumarate tablet) PA > 30 units/month Viread (tenofovir disoproxil fumarate powder) PA 13 years PA Prior authorization is required. The prescriber must obtain prior authorization for the drug in order for the pharmacy to receive payment. Note: Prior authorization applies to both the brand-name and the FDA A -rated generic equivalent of listed product.

5 # This designates a brand-name drug with FDA A -rated generic equivalents. Prior authorization is required for the brand, unless a particular form of that drug (for example, tablet, capsule, or liquid) does not have an FDA A -rated generic equivalent. BP Brand Preferred over generic equivalents. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing the non-preferred drug generic equivalent. * The generic OTC and, if any, generic prescription versions of the drug are payable under MassHealth without prior authorization. This drug is available through the health care professional who administers the drug. MassHealth does not pay for this drug to be dispensed through a retail pharmacy.