Aetna Better Health Illinois Premier Plan. November 2015 Formulary Updates. October 2015 Formulary Updates
|
|
|
- Annabel Ward
- 5 years ago
- Views:
Transcription
1 Aetna Better Health Illinois Premier Plan November 2015 Formulary Updates desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg RIVASTIGMINE DIS 13.3/24; QL (30 patches/30 days) RIVASTIGMINE DIS 4.6MG/24; QL (30 patches/30 days) RIVASTIGMINE DIS 9.5MG/24; QL (30 patches/30 days) ARIPIPRAZOLE SOL 1MG/ML; ST required BRILINTA TAB 60MG REXULTI TAB 0.25MG; QL (360 tabs/30 days) REXULTI TAB 0.5MG; QL (180 tabs/30 days) REXULTI TAB 1MG; QL (90 tabs/30 days) REXULTI TAB 2MG; QL (60 tabs/30 days) REXULTI TAB 3MG; QL (30 tabs/30 days) REXULTI TAB 4MG; QL (30 tabs/30 days) TETRABENAZIN TAB 12.5MG; PA, QL (240 tabs/30 days) TETRABENAZIN TAB 25MG; PA, QL (120 tabs/30 days) VIIBRYD KIT STARTER TEKAMLO TAB MG October 2015 Formulary Updates DACARBAZINE INJ 100MG (PA required) DOCETAXEL INJ 20MG/2ML (PA required) ESOMEPRAZOLE CAP 20 MG ESOMEPRAZOLE CAP 40 MG BEXAROTENE CAP 75MG (PA required) DOCETAXEL INJ 160/16ML (PA required) FARXIGA TAB 10MG (QL 30 tabs/30 days)
2 FARXIGA TAB 5MG (QL 60 tabs/30 days) GLEOSTINE CAP 100MG GLEOSTINE CAP 10MG GLEOSTINE CAP 40MG IRESSA 250MG (PA required) KINRIX INJ MEGESTROL SUS 625MG/5M (PA required) NAMZARIC CAP 14-10MG NAMZARIC CAP 28-10MG ORKAMBI TAB (PA required) QUADRACEL INJ XIGDUO XR TAB (QL 30 tabs/30 days) XIGDUO XR TAB MG (QL 30 tabs/30 days) XIGDUO XR TAB MG (QL 60 tabs/30 days) XIGDUO XR TAB 5-500MG (QL 60 tabs/30 days) APEXICON OIN 0.05% FOSCARNET INJ 24MG/ML TEKAMLO TAB 300-5MG September 2015 Formulary Updates ASPIRIN/DIPYRIDAMOLE CAP MG MEMANTINE TAB HCL 5MG; PA MEMANTINE HC TAB 10MG; PA TRULICITY INJ 0.75/0.5; QL TRULICITY INJ 1.5/0.5; QL GLATOPA (glatiramer acetate) INJ 20MG/ML; PA, QL LINEZOLID TAB 600MG ABILIFY SOL 1MG/ML
3 August 2015 Formulary Updates ALOSETRON TAB 0.5MG; PA ALOSETRON TAB 1MG; PA CLINDAMAX GEL 1% GAVILYTE-H KIT KIMIDESS TAB BEXSERO INJ BREO ELLIPTA INH ; QL CLOZAPINE TAB 150MG/ODT; PA; QL CLOZAPINE TAB 200MG/ODT; PA; QL KUVAN POW 500MG; PA July 2015 Formulary Updates ARIPIPRAZOLE TAB 10MG; QL ARIPIPRAZOLE TAB 15MG; QL ARIPIPRAZOLE TAB 20MG; QL ARIPIPRAZOLE TAB 2MG; QL ARIPIPRAZOLE TAB 30MG; QL ARIPIPRAZOLE TAB 5MG; QL
4 LEVONOR/ETHI TAB FARYDAK CAP 10MG; PA FARYDAK CAP 15MG; PA FARYDAK CAP 20MG; PA FENTORA TAB 100MCG; PA; QL FENTORA TAB 200MCG; PA; QL FENTORA TAB 400MCG; PA; QL FENTORA TAB 600MCG; PA; QL FENTORA TAB 800MCG; PA; QL SAPHRIS SUBLINGUAL 2.5MG; QL TOUJEO SOLO INJ 300IU/ML TUDORZA PRES AER 30 doses; QL ABILIFY SOL 1MG/ML AMTURNIDE TAB AMTURNIDE TAB AMTURNIDE TAB MG AMTURNIDE TAB AMTURNIDE TAB MG ANDROXY TAB 10MG PEDI-DRI POW CUBICIN SOL 500MG VANCOMYCIN INJ 1000MG VANCOMYCIN INJ 10GM June 2015 Formulary Updates CEFIXIME SUS 100/5ML CEFIXIME SUS 200/5ML CORMAX SCALP SOL 0.05% FLUOCIN ACET OIL SCALP TAZICEF INJ 2GM
5 ZENATANE CAP 30MG CHANTIX PAK 1MG; PA GARDASIL 9 INJ LENVIMA CAP 10MG; PA LENVIMA CAP 14MG; PA LENVIMA CAP 20MG; PA LENVIMA CAP 24MG: PA LEVETIRACETAM INJ 10MG/ML LEVETIRACETAM INJ 15MG/ML LEVETIRACETAM INJ 5MG/ML MOVANTIK TAB 12.5MG; QL MOVANTIK TAB 25MG; QL PAZEO DROPS 0.7% PRIFTIN TAB 150MG PRISTIQ TAB 25MG; QL ZYPREXA RELP INJ 210MG; B/D ZYPREXA RELP INJ 300MG; B/D ZYPREXA RELP INJ 405MG; B/D BARACLUDE TAB 0.5MG BARACLUDE TAB 1MG CELEBREX CAP 100MG CELEBREX CAP 200MG CELEBREX CAP 400MG CELEBREX CAP 50MG CELLCEPT SUS 200MG/ML DIOVAN TAB 160MG DIOVAN TAB 320MG DIOVAN TAB 40MG DIOVAN TAB 80MG EXFORGE TAB MG EXFORGE TAB MG EXFORGE TAB 5-160MG EXFORGE TAB 5-320MG EXFORGE HCT/10- TAB EXFORGE HCT/10- TAB EXFORGE HCT/10- TAB EXFORGE HCT/5- TAB EXFORGE HCT/5- TAB INTUNIV TAB 1MG
6 INTUNIV TAB 2MG INTUNIV TAB 3MG INTUNIV TAB 4MG MAFENIDE ACE PAK 5% PATANASE SPR 0.6% RAPAMUNE TAB 1MG RAPAMUNE TAB 2MG SUPRAX TAB 400MG VALCYTE TAB 450MG ZYVOX SOL 2MG/ML May 2015 Formulary Updates TRUMENBA INJ PREZCOBIX TAB EVOTAZ TAB NUTRILIPID EMU 20% IBRANCE CAP 100MG, 125MG, 75MG ILOTYCIN OIN OP DOXY 100 INJ 100MG APEXICON OIN 0.05% April 2015 Formulary Updates LYNPARZA CAP 50MG REYATAZ POW 50MG VITEKTA TAB 150MG RELISTOR KIT 12/0.6ML VITEKTA TAB 85MG
7 deblitane tab 0.35MG tarina fe tab 1/20 digitek tab 0.125MG digitek tab 0.25MG ivermectin tab 3MG deso/ethinyl estradiol tab Generics Removed RELISTOR INJ 12/0.6ML March 2015 Formulary Updates CERDELGA capsule 84 mg, PA HARVONI tablet mg, PA HUMIRA injection 10 mg/0.2, PA OCTAGAM injection 2gm/20ml, PA PURIXAN suspension 20mg/ml SPIRIVA RESPIMAT, QL TREANDA injection 180/2 ml, B vs D TREANDA injection 45/0.5 ml, B vs D ZENPEP capsule unit GAMUNEX-C INJ 40/400ML, PA amlodipine/valsartan/hctz tablet mg, mg, , mg; QL amlodipine/valsartan/hctz tablet mg celecoxib capsule 50 mg, 100 mg, 200 mg, 400 mg; QL guanfacine tablet er, 1 mg, 2 mg, 3 mg, 4 mg lamivudine oral solution 10mg/ml linezolid injection 2mg/ml mycophenolate suspension 200mg/ml; B vs. D olopatadine spray 0.6% potassium chloride tablet 8meq er sirolimus tablet 1mg, 2 mg; B vs. D valganciclovir tablet 450 mg levonorgestrel & ethinyl estradiol (91-day) tab mg Brands Removed HEPARIN SODIUM/NACL injection 1000 unit PRIFTIN tablet 150 mg
8 TIMENTIN injection 3.1 g, 31g Generics Removed e.s.p. suspension mg ees/sulfisoxazole suspenson mg e.s.p. suspension mg PROMACTA TAB 12.5MG-QL from 240 amount, 30 days increased to 360 amount, 30 days PROMACTA TAB 25MG-QL from 120 amount, 30 days increased to 180 amount, 30 days PROMACTA TAB 50MG-QL from 60 amount, 30 days increased to 90 amount, 30 days PROMACTA TAB 75MG-QL from 60 amount, 30 days increased to 30 amount, 30 days January 2015 Formulary Updates CYCLOPHOSPHAMIDE Capsule 25 mg, 50mg, PA, B vs D REVATIO Suspension 10 mg/ml, QL, PA SOMAVERT Injection 25mg, 30mg, PA TRIUMEQ Tablet TYBOST Tablet 150mg XARELTO STARTER PACK Tablet 15/20 mg Amlodipine/valsartan Tablet mg, mg, mg, QL Amlodipine/valsartan Tablet mg SHAROBEL Tablet mg Amlodipine/valsartan Tablet mg, mg, mg, QL Amlodipine/valsartan Tablet mg SHAROBEL Tablet mg Amlodipine/valsartan Tablet mg, mg, mg, QL Amlodipine/valsartan Tablet mg SHAROBEL Tablet mg Changes NAMENDA XR Capsules 7 mg, 14 mg, removed QL NAMENDA Tablet 5 mg, 10 mg, PA added NAMENDA XR Capsules 7 mg, 14 mg, removed QL
9
Medicare Part D 2016 Formulary Changes Service To Senior and OC Preferred
Medicare Part D 2016 Formulary s Service To Senior and OC Preferred Inter Valley Health Plan may add or remove drugs from our formulary during the year. If we remove a drug from our formulary, add prior
Medicare Part D 2016 Formulary Changes Desert Preferred Choice
Medicare Part D 2016 Formulary s Desert Preferred Choice Inter Valley Health Plan may add or remove drugs from our formulary during the year. If we remove a drug from our formulary, add prior authorization,
Medicare Part D 2015 Formulary Changes Desert Preferred Choice
Medicare Part D 2015 Formulary s Desert Preferred Choice Inter Valley Health Plan may add or remove drugs from our formulary during the year. If we remove a drug from our formulary, add prior authorization,
Medicare Part D 2016 Formulary Changes Service To Senior and OC Preferred
Medicare Part D 2016 Formulary s Service To Senior and OC Preferred Inter Valley Health Plan may add or remove drugs from our formulary during the year. If we remove a drug from our formulary, add prior
Aetna Better Health of Illinois Medicaid Formulary Updates
October 2017 o DOXYLAMINE SUCCINATE 25mg-QL o DULOXETINE CAP 40MG DR-QL o GUANFACIN ER TABS (all strengths)-ql o TOBRAMYCIN NEBU SOLUTION- PA August 2017 Aetna Better Health of Illinois Medicaid 2017 Formulary
Network Health Insurance Corporation Upcoming Negative Changes to the Medicare Part D Formulary
Requesting an Exception to the Formulary You can ask Network Health Insurance Corporation to make an exception to our coverage rules. Generally, we will only approve your request for an exception if alternative
2018 CareOregon Advantage Part D Formulary Changes
2018 CareOregon Advantage Part D Formulary Changes Abbreviations: AGE = Age Restriction; PA = Prior Authorization Required; QL = Quantity Limit; ST = Step Therapy Required; LD = Limited Distribution; BvD
Santa Clara Family Health Plan Cal MediConnect Formulary. List of Step Therapy Requirements Effective: 12/01/ E
Santa Clara Family Health Plan Cal MediConnect Formulary List of Step Therapy Requirements Effective: 12/01/2018 13027.12E ANTICONVULSANTS APTIOM 200 MG TABLET APTIOM 400 MG TABLET APTIOM 600 MG TABLET
FirstCarolinaCare Insurance Company. Step Therapy Requirements
FirstCarolinaCare Insurance Company Step Therapy Requirements Effective: 12/01/2018 ANTICONVULSANTS APTIOM 200 MG APTIOM 400 MG APTIOM 600 MG APTIOM 800 MG BANZEL 200 MG BANZEL 40 MG/ML ORAL SUSPENSION
ANTICONVULSANTS. Details. Step Therapy Criteria Date Effective: April 1, 2019
Step Therapy Date Effective: April 1, 2019 ANTICONVULSANTS APTIOM TABLET 200 MG ORAL APTIOM TABLET 400 MG ORAL APTIOM TABLET 600 MG ORAL APTIOM TABLET 800 MG ORAL BANZEL SUSPENSION 40 MG/ML ORAL BANZEL
Step Therapy Requirements. Effective: 11/01/2018
Effective: 11/01/2018 Updated 10/2018 ANTIDEPRESSANTS Sharp Health Plan (HMO) TRINTELLIX 10 MG TABLET TRINTELLIX 20 MG TABLET TRINTELLIX 5 MG TABLET VIIBRYD 10 MG (7)-20 MG (23) TABLETS IN A DOSE PACK
SecureBlue Formulary 2016 Master Negative Changes from 2015 to 2016
Beta-lactam, SUPRAX TAB 400MG Suprax 400 mg cap Antibacterials Cephalosporins Beta-lactam, CEFOTAXIME INJ 10GM cefotaxime 2 gm inj Antibacterials Cephalosporins ERYTHROCIN INJ 1000MG Erythrocin 500 mg
August 2016 Formulary Updates
August 2016 Formulary Updates DOXYCYCLINE HYCLATE TABS DR 50MG, 200MG NALOXONE HCL INJ 0.4MG/ML VANCOMYCIN HCL INJ 500MG, 750MG BRIVIACT INJ - PA BRIVIACT ORAL SOLN - QL; PA BRIVIACT TABS - QL; PA LENVIMA
Superior Select Health Plans: Tribute-1 Tier May 2018 Formulary Addendum
Superior Select Health Plans: Tribute-1 Tier May 2018 Formulary Addendum Below is a list formulary changes for the benefit year 2018. This is not a complete list of drugs covered by the Part D plan. The
Step Therapy Requirements. Effective: 1/1/2019
Effective: 1/1/2019 Updated 1/2019 AMANTADINE ER Sharp Health Plan (HMO) OSMOLEX ER 129 MG, EXTENDED RELEASE OSMOLEX ER 193 MG, EXTENDED RELEASE OSMOLEX ER 258 MG, EXTENDED RELEASE PRIOR CLAIM FOR AMANTADINE
ANTIDIABETIC AGENTS - MISCELLANEOUS
ANTIDIABETIC AGENTS - MISCELLANEOUS Glyxambi 10 mg-5 mg tablet Glyxambi 25 mg-5 mg tablet Invokamet 150 mg-1,000 mg tablet Invokamet 150 mg-500 mg tablet Invokamet 50 mg-1,000 mg tablet Invokamet 50 mg-500
Health Partners Medicare Prime 2019 Formulary Changes
Health Partners Medicare Prime 2019 Formulary Changes Changes occur, for example, because new drugs come on the market, a drug is moved to a different cost-sharing level (tier), or a generic version becomes
ANTIDIABETIC AGENTS - MISCELLANEOUS
ANTIDIABETIC AGENTS - MISCELLANEOUS Glyxambi 10 mg-5 mg tablet Glyxambi 25 mg-5 mg tablet Invokamet 150 mg-1,000 mg tablet Invokamet 150 mg-500 mg tablet Invokamet 50 mg-1,000 mg tablet Invokamet 50 mg-500
AMANTADINE ER. Products Affected Step 2: OSMOLEX ER 129 MG TABLET, EXTENDED RELEASE OSMOLEX ER 193 MG TABLET, Details
AMANTADINE ER OSMOLEX ER 129 MG TABLET, EXTENDED RELEASE OSMOLEX ER 193 MG TABLET, EXTENDED RELEASE OSMOLEX ER 258 MG TABLET, PRIOR CLAIM FOR AMANTADINE HCL IMMEDIATE RELEASE WITHIN THE PAST 120 DAYS.
AMANTADINE ER. Products Affected Step 2: OSMOLEX ER 129 MG TABLET, EXTENDED RELEASE OSMOLEX ER 193 MG TABLET, Details
AMANTADINE ER OSMOLEX ER 129 MG TABLET, EXTENDED RELEASE OSMOLEX ER 193 MG TABLET, EXTENDED RELEASE OSMOLEX ER 258 MG TABLET, PRIOR CLAIM FOR AMANTADINE HCL IMMEDIATE RELEASE WITHIN THE PAST 120 DAYS.
Medicare Part D 2017 Formulary Changes OC Preferred
Medicare Part D 2017 Formulary Changes OC Preferred Inter Valley Health Plan may add or remove drugs from our formulary during the year. If we remove a drug from our formulary, add prior authorization,
True Health New Mexico List of Medications with Quantity Limits
True Health New Mexico List of Medications with Quantity Limits Specialty Medications Contact True Health New Mexico Pharmacy Services at 1-866- 341-8561 for quantity limits on specialty medications. Maximum
ANTIDIABETIC AGENTS - MISCELLANEOUS
ANTIDIABETIC AGENTS - MISCELLANEOUS GLYXAMBI 10 MG-5 MG GLYXAMBI 25 MG-5 MG INVOKAMET 150 MG-1,000 MG INVOKAMET 150 MG-500 MG INVOKAMET 50 MG-1,000 MG INVOKAMET 50 MG-500 MG INVOKAMET XR 150 MG-1,000 MG,
ANTICONVULSANTS. Details
ANTICONVULSANTS Aptiom 200 mg tablet Aptiom 400 mg tablet Aptiom 600 mg tablet Aptiom 800 mg tablet Banzel 200 mg tablet Banzel 40 mg/ml oral suspension Banzel 400 mg tablet Fycompa 0.5 mg/ml oral suspension
Memorial Hermann Advantage HMO February 2019 Formulary Addendum
Memorial Hermann Advantage HMO February 2019 Formulary Addendum Changes may have occurred since the printing of your current Memorial Hermann Advantage HMO Formulary. Medications that may have been added
ANTICONVULSANTS. Details
ANTICONVULSANTS APTIOM 200 MG TABLET APTIOM 400 MG TABLET APTIOM 600 MG TABLET APTIOM 800 MG TABLET BANZEL 200 MG TABLET BANZEL 40 MG/ML ORAL SUSPENSION BANZEL 400 MG TABLET FYCOMPA 0.5 MG/ML ORAL SUSPENSION
AMANTADINE ER. Products Affected Step 2: OSMOLEX ER 129 MG TABLET, EXTENDED RELEASE OSMOLEX ER 193 MG TABLET, Details
AMANTADINE ER OSMOLEX ER 129 MG, EXTENDED RELEASE OSMOLEX ER 193 MG, EXTENDED RELEASE OSMOLEX ER 258 MG, EXTENDED RELEASE PRIOR CLAIM FOR AMANTADINE HCL IMMEDIATE RELEASE WITHIN THE PAST 120 DAYS. 1 ANTICONVULSANTS
ANTICONVULSANTS. Details
ANTICONVULSANTS Aptiom 200 mg tablet Aptiom 400 mg tablet Aptiom 600 mg tablet Aptiom 800 mg tablet Banzel 200 mg tablet Banzel 40 mg/ml oral suspension Banzel 400 mg tablet Fycompa 0.5 mg/ml oral suspension
Aetna Better Health FIDA Plan
Aetna Better Health FIDA Plan May 2016 Formulary Updates ASCOMP/COD - QL; PA FYAVOLV 5MCG; 1MG- PA METOPROLOL TABS 37.5MG, 75MG CIPRODEX LETAIRIS - QL; PA OFEV - QL; PA OTREXUP - ST PRALUENT - QL; PA RASUVO
ANTIDEPRESSANTS. Details. dose pack Viibryd 10 mg tablet Viibryd 20 mg tablet Viibryd 40 mg tablet. Criteria
ANTIDEPRESSANTS Trintellix 10 mg tablet Trintellix 20 mg tablet Trintellix 5 mg tablet Viibryd 10 mg (7)-20 mg (23) tablets in a dose pack Viibryd 10 mg tablet Viibryd 20 mg tablet Viibryd 40 mg tablet
Partners Notice of Change March 2017
New Added Products: Effective 3/1/2017 Drug Reason Tier Restrictions abacavir 600 mg-lamivudine 300 QL ADRENACLICK 0.15 MG/0.15 ML INJECTION,AUTO- INJECTOR ADRENACLICK 0.3 MG/0.3 ML INJECTION, AUTO- INJECTOR
Medicare Part D Drugs that Require Step Therapy Effective 12/01/2017
Medicare Part D Drugs that Require Step Therapy Effective 12/01/2017 Providers may call the Pharmacy Help Desk at 800-641-8921 for more information or questions about criteria. The formulary may change
December 2016 Formulary Updates
December 2016 Formulary Updates ABACAVIR/LAMIVUDINE AMLODIPINE/OLMESARTAN MEDOXOMIL TAB 10-20MG QL AMLODIPINE/OLMESARTAN MEDOXOMIL TAB 10-40MG QL AMLODIPINE/OLMESARTAN MEDOXOMIL TAB 5-20MG QL AMLODIPINE/OLMESARTAN
Medicare Part D 2017 Formulary Changes Service To Senior
Medicare Part D 2017 Formulary s Service To Senior Inter Valley Health Plan may add or remove drugs from our formulary during the year. If we remove a drug from our formulary, add prior authorization,
Medicare Part D 2012 Formulary Changes Service To Senior and Total Fit
Medicare Part D 2012 Formulary s Service To Senior and Total Fit Inter Valley Health Plan may add or remove drugs from our formulary during the year. If we remove a drug from our formulary, add prior authorization,
Step Therapy Requirements. Effective: 05/01/2018
Step Therapy Requirements Effective: 05/01/2018 ANTIDEPRESSANTS TRINTELLIX 10 MG TABLET TRINTELLIX 20 MG TABLET TRINTELLIX 5 MG TABLET VIIBRYD 10 MG (7)-20 MG (23) TABLETS IN A DOSE PACK VIIBRYD 10 MG
Medicare Part D 2017 Formulary Changes OC Preferred
Medicare Part D 017 Formulary s OC Preferred Inter Valley Health Plan may add or remove drugs from our formulary during the year. If we remove a drug from our formulary, add prior authorization, quantity
VNSNY CHOICE FIDA Complete Step Therapy Requirements. Effective: 01/01/2017
VNSNY CHOICE FIDA Complete Step Therapy Requirements Effective: 01/01/2017 Updated 12/23/2016 ANTICONVULSANTS Aptiom 200 mg tablet Potiga 200 mg tablet Aptiom 400 mg tablet Potiga 300 mg tablet Aptiom
Step Therapy Requirements. Effective: 12/01/2016
Effective: 12/01/2016 H2986_PD_049 Updated 11/2016 ALPHA 1-PROTEINASE INHIBITOR GLASSIA PRIOR CLAIM FOR ARALAST NP OR ZEMAIRA WITHIN THE PAST 120 DAYS. ANALGESICS, NARCOTICS KADIAN MORPHINE SULFATE ER
Changes to the 2018 BlueCross Secure SM (HMO) & BlueCross Total SM (PPO) Formularies
Changes to the 2018 BlueCross Secure SM (HMO) & BlueCross Total SM (PPO) Formularies BlueCross BlueShield of South Carolina may add or remove drugs from the formulary during the year. If we remove drugs
**CRITERIA UNDER CMS REVIEW**
**CRITERIA UNDER CMS REVIEW** ANTICONVULSANTS APTIOM TABLET 200 MG APTIOM TABLET 400 MG APTIOM TABLET 600 MG APTIOM TABLET 800 MG BANZEL SUSPENSION 40 MG/ML BANZEL TABLET 200 MG BANZEL TABLET 400 MG BRIVIACT
Step Therapy Requirements
Step Therapy Requirements Denver Health Medicare Choice (HMO SNP)/Medicare Select (HMO) Effective: 09/01/2017 Updated 08/2017 ANTICONVULSANTS Aptiom 200 mg tablet Aptiom 400 mg tablet Aptiom 600 mg tablet
Medicare Part D 2017 Formulary Changes Service To Senior
Medicare Part D 2017 Formulary Changes Service To Senior Inter Valley Health Plan may add or remove drugs from our formulary during the year. If we remove a drug from our formulary, add prior authorization,
ANTICONVULSANTS. Details
ANTICONVULSANTS APTIOM 200 MG APTIOM 400 MG APTIOM 600 MG APTIOM 800 MG BANZEL 200 MG BANZEL 40 MG/ML ORAL SUSPENSION BANZEL 400 MG FYCOMPA 0.5 MG/ML ORAL SUSPENSION FYCOMPA 10 MG FYCOMPA 12 MG FYCOMPA
VNSNY CHOICE FIDA Complete Step Therapy Requirements. Effective: 04/01/2019
VNSNY CHOICE FIDA Complete Step Therapy Requirements Effective: 04/01/2019 Updated 03/2019 AMANTADINE ER OSMOLEX ER 129 MG, EXTENDED RELEASE OSMOLEX ER 193 MG, EXTENDED RELEASE OSMOLEX ER 258 MG, EXTENDED
Pharmacy Updates Summary
All of the following changes were reviewed and approved by the SFHP Pharmacy & Therapeutics (P&T) Committee on 04/15/2015 Effective date: 05/15/2015 Therapeutic Classes reviewed: Testosterone replacement
VIVA MEDICARE IMPORTANT T EXPANDED PERFORMANCE FORMULARY UPDATES
NORE/ETH/FER CHW 0.MG Added to the 07 //07 ALYACEN TAB / Added to the 07 //07 AMETHIA LO TAB Added to the 07 //07 ERGOT/CAFFEN TAB 00MG Added to the 07 //07 NORETH/ETHIN TAB /0 Added to the 07 //07 LORCET
2017 Formulary Addendum Notice of Change (Medicare Advantage Plans)
207 Formulary Addendum Notice of Change (Medicare Advantage Plans) Easy Choice Health Plan Easy Choice Plus Plan (HMO) H5087-002, H5087-07 This is a listing of the changes that have occurred in our formulary.
Health Partners Medicare Special 2018 Formulary Changes
Health Partners Medicare Special 2018 Changes Changes occur, for example, because new drugs come on the market, a drug is moved to a different cost-sharing level (tier), or a generic version becomes available.
2018 Formulary Notice of Change Prescription Drug Plans
2018 Formulary Notice of Change Prescription Drug Plans WellCare Prescription Insurance, Inc. Plans in all states: WellCare Classic (PDP) WellCare may add or remove drugs from our formulary during the
2017 Formulary Addendum Notice of Change (Medicare Advantage Plans)
2017 Formulary Addendum Notice of Change (Medicare Advantage Plans) Easy Choice Health Plan Easy Choice Best Plan (HMO) H5087-005 This is a listing of the changes that have occurred in our formulary. Please
November 2016 Formulary Updates
November 2016 Formulary Updates DAPTOMYCIN LARISSIA NITROGLYCERIN SUBL ORFADIN 20MG CAP PA RELISTOR 150MG TAB PA; QL Over-the-Counter (OTC) Drugs Added* COLEMAN SKINSMART INSECT REP CUTTER BACKWOODS AERO
Blue Cross and Blue Shield of Minnesota GenRx Formulary Updates
Blue Cross and Blue Shield of Minnesota GenRx Formulary Updates July 2018 TRADE NAME (generic name) or generic name ADVAIR DISKUS (fluticasone-salmeterol aer powder ba 100-50 mcg/dose) Brand Addition ADVAIR
UPDATE Ohana QUEST Integration Medicaid
UPDATE Ohana QUEST Integration Medicaid Preferred Drug List June 29, 2015 Dear Provider: At the June 04, 2015 WellCare Pharmacy & Therapeutics Committee meeting, it was decided that the following changes
Medicare Part D 2017 Formulary Changes OC Preferred
Medicare Part D 2017 Formulary s OC Preferred Inter Valley Health Plan may add or remove drugs from our formulary during the year. If we remove a drug from our formulary, add prior authorization, quantity
2016 FORMULARY ADDENDUM NOTICE OF CHANGE
2016 FORMULARY ADDENDUM NOTICE OF CHANGE (PRESCRIPTION DRUG PLANS) WELLCARE PRESCRIPTION INSURANCE, INC. WellCare Simple (PDP) WellCare Classic (PDP) WellCare Extra (PDP) This is a listing of the changes
2016 Medicare Part D Formulary Change
2016 Medicare Part D Formulary Change We may add or remove drugs from our formulary during the year. If we remove drugs from our formulary, or add prior authorizations, quantity limits and/or step therapy
VIVA Health, Inc. Part D Cumulative Formulary Changes for 2009
ulary ulary Effective ADDS 00472088282 ACETASOL HC 2%; 1% SOLN Pref(1) no 1/29/2009 3/1/2009 68382026101 ACETAZOLAMIDE 500MG CP12 Pref(1) yes 3/24/2009 5/1/2009 00078056651 AFINITOR 5MG TABS Pref (4);
2018 Medicare Part D Formulary Change
2018 Medicare Part D Formulary Change We may add or remove drugs from our formulary during the year. If we remove drugs from our formulary, or add prior authorizations, quantity limits and/or step therapy
Rationale for Decision Excluded Generic OTC equivalent available (Flonase Allergy Relief) Medicare status (if differs)
BLUE SHIELD OF CALIFORNIA FIRST QUARTER 2015 FORMULARY AND MEDICATION POLICY UPDATES EFFECTIVE MARCH 19, 2015 The Blue Shield of California (BSC) Pharmacy and Therapeutics (P&T) Committee, consisting of
Quarterly pharmacy formulary change notice
Provider update Quarterly pharmacy formulary change notice Summary: The formulary changes listed in the table below were reviewed and approved at our first-quarter 2018, Pharmacy and Therapeutics Committee
2018 Step Therapy Criteria
2018 Step Therapy Criteria ANGIOTENSIN RECEPTOR BLOCKERS... 2 ANTIDEPRESSANTS... 3 ANTIDEPRESSANTS, MISCELLANEOUS... 4 ANTIDEPRESSANTS, OTHER... 5 ANTIDIABETIC AGENTS... 6 ANTIGOUT AGENTS... 7 ANTIHYPERTENSIVE
NOTIFICATION OF FORMULARY CHANGES
NOTIFICATION OF CHANGES The following summary describes changes to the 2018 Presbyterian Senior Care (HMO)/(HMO-POS), Presbyterian MediCare PPO and formularies. The formulary may change at any time. You
WellCare s South Carolina Preferred Drug List Update
WellCare s South Carolina Preferred Drug List Update This is a list of changes to our preferred drug list. These are a result of the latest WellCare Pharmacy & Therapeutics meeting held on 09/21/2017.
WellCare s South Carolina Preferred Drug List Update
WellCare s South Carolina Preferred Drug List Update This is a list of changes to our preferred drug list. These are a result of the latest WellCare Pharmacy & Therapeutics meeting held on 09/03/2015.
December 2016 Formulary Updates
December 2016 Formulary Updates ABACAVIR/LAMIVUDINE AMLODIPINE/OLMESARTAN MEDOXOMIL TAB 10-20MG QL AMLODIPINE/OLMESARTAN MEDOXOMIL TAB 10-40MG QL AMLODIPINE/OLMESARTAN MEDOXOMIL TAB 5-20MG QL AMLODIPINE/OLMESARTAN
2018 Medicare Part D Formulary Change
2018 Medicare Part D Formulary Change We may add or remove drugs from our formulary during the year. If we remove drugs from our formulary, or add prior authorizations, quantity limits and/or step therapy
WVCH Formulary Additions Effective 01/01/2016 Name Strength Dosage Form Route Formulary Restrictions
WVCH Formulary Additions Effective 01/01/2016 Name Strength Dosage Form Route Formulary Restrictions ANORO ELLIPTA 62.5-25MCG BLST W/DEV INHALATION ARCAPTA NEOHALER 75 MCG CAP W/DEV INHALATION CALCIPOTRIENE
Step Therapy Requirements
An Independent Licensee of the Blue Cross and Blue Shield Association Step Therapy Requirements Effective: 12/01/2017 Updated 11/2017 H0302_2_2014 CMS Accepted 05/05/2014 1 ABILIFY Abilify 10 mg tablet
ABILIFY INJ. Products Affected Step 2: ABILIFY MAINTENA PREFILLED SYRINGE 300 MG INTRAMUSCULAR ABILIFY MAINTENA PREFILLED SYRINGE 400 MG INTRAMUSCULAR
ABILIFY INJ ABILIFY MAINTENA PREFILLED SYRINGE 300 MG ABILIFY MAINTENA PREFILLED SYRINGE 400 MG ABILIFY MAINTENA SUSPENSION RECONSTITUTED ER 300 MG Claim will pay automatically for ABILIFY MAINTENA if
Quarterly pharmacy formulary change notice
Quarterly pharmacy formulary change notice Provider update Summary: Effective August 1, 2018, the preferred formulary changes detailed in the table below will apply to District of Columbia Healthy Families
2018 Formulary Update
MEDICARE ADVANTAGE BlueShield of Northeastern New York 2018 Formulary Update BlueShield of Northeastern New York has updated its formulary (drug list) since its original publication in January 2018. This
5-ASA. Products Affected DIPENTUM 250 MG CAPSULE LIALDA 1.2 GRAM TABLET,DELAYED RELEASE. Details
5-ASA DIPENTUM 250 MG CAPSULE LIALDA 1.2 GRAM TABLET,DELAYED You are required to have previous therapy with balsalazide, Delzicol, Apriso, or Asacol HD before we will cover Lialda or Dipentum. 1 ANTIEMETICS
5-ASA. Products Affected. Details. Dipentum 250 mg capsule. Lialda 1.2 gram tablet,delayed release
Updated 11/1/17 5-ASA Dipentum 250 mg capsule Lialda 1.2 gram tablet,delayed release You are required to have previous therapy with balsalazide, Delzicol, Apriso, or Asacol HD before we will cover Lialda
March 2017 P&T Updates
March 2017 P&T Updates Commercial Triple Tier 4th Tier Applicable Traditional Prior Auth DICLEGIS 3 No 2 No Yes EMVERM 2 No 2 Yes Yes Detailed s 4 tablets per day, 9 month supply per year Pinworms: 1 tablet
Harvard Pilgrim Health Care Stride SM Basic Rx (HMO), Stride SM Value Rx (HMO), Stride SM Value Rx Plus (HMO) and Stride SM Gain Rx (HMO)
Harvard Pilgrim Health Care Stride SM Basic Rx (HMO), Stride SM Value Rx (HMO), Stride SM Value Rx Plus (HMO) and Stride SM Gain Rx (HMO) Step Therapy Requirements Effective 4/1/2019 Updated 3/2019 BRAND
2018 PDP Premier Step Therapy Document September 2018 Y0114_18_33144_I_009
2018 PDP Premier Step Therapy Document September 2018 Aggrenox Y0114_18_33144_I_009 aspirin 25 mg-dipyridamole 200 mg capsule,ext.release 12 hr multiphase drug may be given. Step 1 Drug(s): clopidigrel.
Granite Alliance Insurance Company (PDP) 2018 Step Therapy Criteria Last Updated: 10/23/18
Granite Alliance Insurance Company (PDP) 2018 Step Therapy Criteria Last Updated: 10/23/18 Granite Alliance requires step therapy for certain drugs. This means prior to receiving a drug with a step therapy
Harvard Pilgrim Health Care Stride SM Basic Rx (HMO), Stride SM Value Rx (HMO) and Stride SM Value Rx Plus (HMO) Step Therapy Requirements
Harvard Pilgrim Health Care Stride SM Basic Rx (HMO), Stride SM Value Rx (HMO) and Stride SM Value Rx Plus (HMO) Step Therapy Requirements Effective 7/1/2018 Updated 6/2018 BRAND NAME ANTIDEPRESSANTS APLENZIN
2017 Formulary Addendum Notice of Change
017 Formulary Addendum Notice of Change (Medicare Advantage Plans) WellCare Health Plans WellCare Choice (HMO), WellCare Essential (HMO-POS), WellCare Value (HMO) This is a listing of the changes that
2017 Step Therapy Criteria
FRESENIUS TOTAL HEALTH 2017 Step Therapy Updated 07/01/2017. For more recent information or other questions, please contact Fresenius Total Health Customer Service at 1-855-598-6774 / TTY 1-844-209-9094.
Quarterly pharmacy formulary change notice
Quarterly pharmacy formulary change notice Summary of change: The Pharmacy and Therapeutics Committee (P&T) reviewed and approved the formulary changes listed in the table below on March 29, 2016. What
Quarterly Pharmacy Formulary Change Notice
MEDICAID PROVIDER BULLETIN February 26, 2015 Quarterly Pharmacy Formulary Change Notice Summary of Change: The formulary changes listed in the table below were reviewed and approved at our September 24,
2017 Formulary Addendum Notice of Change (Prescription Drug Plans)
2017 Formulary Addendum Notice of Change (Prescription Drug Plans) WellCare Prescription Insurance, Inc. WellCare Classic (PDP) WellCare Extra (PDP) This is a listing of the changes that have occurred
Acyclovir Ointment. Aetna Better Health Pennsylvania. Products Affected. acyclovir ointment 5 % external Details. Criteria
Medications that require Step Therapy (ST) require trial and failure of preferred formulary agents prior to their authorization. If the prerequisite medications have been filled within the specified time
Quarterly pharmacy formulary change
Medi-Cal Managed Care L. A. Care Major Risk Medical Insurance Program Provider Bulletin The formulary changes listed in the table below were reviewed and approved at our first-quarter 2018 Pharmacy and
WellCare Signature (PDP) and WellCare Classic (PDP) Formulary Addendum
WellCare Signature (PDP) and WellCare Classic (PDP) Formulary Addendum This is a listing of the changes that have occurred in our formulary. Please carefully review these changes and call WellCare if you
ALLERGIC CONJUNCTIVITIS AGENTS
2018 5 Tier Standard- Keystone First VIP Choice Document: 2018 Step Therapy Formulary ID: 18390 Last Updated: 04/2018 Effective Date: 05-01-2018 ALLERGIC CONJUNCTIVITIS AGENTS epinastine 0.05 % eye drops
THERAPEUTIC AREA NAME STRENGTH DOSAGE FORM
Value Based Tier Drugs are selected for the management of Asthma, Diabetes, Hypertension and Hyperlipidemia. These drugs are covered at no charge or at a reduced cost share. Medications are under continual
Neighborhood Medicaid Formulary Changes: June 2017
Neighborhood Medicaid Formulary Changes: June 2017 The following changes to the Neighborhood Medicaid Formulary were recently approved by the Pharmacy and Therapeutics (P&T) Committee. All changes were
March 2018 P & T Updates
March 2018 P & T Updates Commercial Triple Tier 4th Tier Applicable Traditional Prior Auth AURYXIA 3 2 12 tablets per BAXDELA TABLETS 3 2 2 tablets per Depending on your specific benefits and in which
Quarterly pharmacy formulary change notice
Provider Bulletin April 2018 This table is used by HealthKeepers, Inc. to indicate formulary changes applicable to all Anthem HealthKeepers Plus members. These changes were reviewed and approved at the
JULY 2017 ADDITIONS. NP Thyroid 120mg NP Thyroid 15mg JUNE 2017 CHANGES
APRIL 2017 Ivermectin, Pin-X and Reeses (Pyrantel Pamoate) Selzentry 25mg and 75mg tablets Linzess 72 mcg capsule-with QLL Levalbuterol Tartrate Inhal Aerosol (Generic Xopenex HFA) with ST & QLL Jentadueto