April 19, 2023
The Children with Special Health Care Needs Services Program (CSHCN) completed a review of its program formulary with consideration of utilization, available treatment alternatives, and best value for the program. CSHCN will remove the following drugs from its formulary on June 1, 2023. CSHCN may remove additional drugs if utilization, available treatment alternatives, and best value indicate it is appropriate.
| NDC | Drug Name |
|---|---|
| 52856050403 | EMFLAZA 36 MG TABLET |
| 52856050522 | EMFLAZA 22.75 MG/ML ORAL SUSP |
| 52856050101 | EMFLAZA 6 MG TABLET |
| 52856050203 | EMFLAZA 18 MG TABLET |
| 52856050303 | EMFLAZA 30 MG TABLET |
| 79378011001 | LIVMARLI 9.5 MG/ML ORAL SOLN |
| 75987014513 | PROCYSBI DR 300 MG GRANULE PKT |
| 75987010004 | PROCYSBI DR 25 MG CAPSULE |
| 75987010108 | PROCYSBI DR 75 MG CAPSULE |
| 75987014013 | PROCYSBI DR 75 MG GRANULE PKT |
| 75987014014 | PROCYSBI DR 75 MG GRANULE PKT |
| 75987014514 | PROCYSBI DR 300 MG GRANULE PKT |
| 75987005006 | RAVICTI 1.1 GRAM/ML LIQUID |
| 67386021165 | SABRIL 500 MG POWDER PACKET |
| 67386011101 | SABRIL 500 MG TABLET |
| 57894006003 | STELARA 45 MG/0.5 ML SYRINGE |
| 57894006103 | STELARA 90 MG/ML SYRINGE |
| 57894006002 | STELARA 45 MG/0.5 ML VIAL |
| 00245055650 | VIGADRONE 500 MG POWDER PACKET |