June 2019

Utilization Management Changes

Brand Name

Corresponding Generic Name


UM Change

Common Use


buprenorphine hcl

75, 150, 300, 450, 600, 750, 900 MCG FILM

ST removed

Moderate-to-severe pain


lurasidone hcl

20, 40, 60, 80, 120 MG TABLET

ST removed

Schizophrenia, bipolar disorder



500, 1,000 MG TABLET

ST removed

Chronic angina

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