Elderplan Formulary Addendum

Transcription

1 2018 Elderplan Formulary Addendum Below is a list of formulary changes for the benefit year This is not a complete list of drugs covered by Elderplan. The formulary changes are reflected in the 2018 downloadable formulary on the Elderplan website. For a complete list of drugs covered by Elderplan please visit our Web site at or call Member Services at , seven days a week, between the hours of 8 a.m. to 8 p.m. TTY/TDD users should call 711. ADAPALENE CRE 0.1% TRETINOIN CRE, AVITA CRE ADAPALENE GEL 0.1% TRETINOIN GEL, AVITA GEL AXIRON SOL 30MG/ACT BUSULFEX INJ 6MG/ML CIPROFLOXACN TAB 1000MG CIPROFLOXACN TAB 500MG ER CUBICIN SOL 500MG DIAZEPAM GEL 10MG DIAZEPAM GEL 2.5MG DIAZEPAM GEL 20MG DIPENTUM CAP 250MG Note: DIAZEPAM GEL has been Note: DIAZEPAM GEL has been Note: DIAZEPAM GEL has been TESTOSTERONE GEL 1%, ANDRODERM DIS, TESTOSTERONE CYPIONATE INJ, TESTOSTERONE ENANTHATE INJ BUSULFAN INJ 6MG/ML (GENERIC OF BUSULFEX) CIPROFLOXACIN TAB 500MG, LEVOFLOXACIN TAB CIPROFLOXACIN TAB 250MG, LEVOFLOXACIN TAB DAPTOMYCIN INJ (GENERIC OF CUBICIN) DIASTAT ACDL GEL DIASTAT PED GEL DIASTAT ACDL GEL APRISO CAP, DELZICOL CAP

2 2 EFFIENT TAB 10MG EFFIENT TAB 5MG PRASUGREL TAB 10MG (GENERIC OF EFFIENT), CLOPIDOGREL TAB, BRILINTA TAB PRASUGREL TAB 5MG (GENERIC OF EFFIENT), CLOPIDOGREL TAB, BRILINTA TAB ELIXOPHYLLIN ELX 80/15ML THEOPHYLLINE SOL 80/15ML ELMIRON CAP 100MG EMEND CAP 125MG EMEND CAP 40MG EMEND CAP 80MG EMEND TRIPAC PAK 80 & 125 EPIPEN 2-PAK INJ 0.3MG EPIPEN-JR INJ 2-PAK APREPITANT CAP (GENERIC OF EMEND) APREPITANT CAP (GENERIC OF EMEND) APREPITANT CAP (GENERIC OF EMEND) APREPITANT PAK (GENERIC OF EMEND TRIPACK) EPINEPHRINE INJ 0.3MG (GENERIC OF ADRENACLICK) EPINEPHRINE INJ 0.15MG (GENERIC OF ADRENACLICK) EURAX CRE 10% PERMETHRIN CRE 5% EURAX LOT 10% PERMETHRIN CRE 5% EXJADE TAB 125MG JADENU TAB EXJADE TAB 250MG JADENU TAB EXJADE TAB 500MG JADENU TAB FERRIPROX SOL 100MG/ML JADENU SPRKL GRA FERRIPROX TAB 500MG JADENU TAB FLUOXETINE TAB 10MG FLUOXETINE CAP 10MG FLUOXETINE TAB 20MG FLUOXETINE CAP 20MG

3 3 FUSILEV INJ 50MG HYDROXYZ PAM CAP 100MG KALETRA SOL LANTUS INJ 100/ML LANTUS INJ SOLOSTAR LEVOLEUCOVORIN CALCIUM 50MG (GENERIC OF FUSILEV) LEVOCETIRIZINE DIHYDROCHLORIDE TAB 5 MG, HYDROXYZINE PAMOATE CAP 50MG, HYDROXYZINE HCL TAB LOPINAVIR-RITONAVIR SOLN (GENERIC OF KALETRA) BASAGLAR, LEVEMIR, TRESIBA BASAGLAR, LEVEMIR, TRESIBA LEUKINE INJ 250MCG NEUPOGEN, GRANIX MAXIDEX SUS 0.1% OP METHERGINE TAB 0.2MG MOLINDONE TAB HCL 10MG MOLINDONE TAB HCL 25MG NEORAL CAP 100MG NEORAL CAP 25MG NEORAL SOL 100MG/ML NEXIUM GRA 10MG DR Note: MOLINDONE TAB has been Note: MOLINDONE TAB has been DEXAMETHASONE SODIUM PHOSPHATE OPHTH SOLN 0.1%, PREDNISOLONE SUS 1% OP OR SOD PHO SOL 1% OP, FLUOROMETHOL SUS 0.1% OP, LOTEMAX, DUREZOL EMU 0.05% RISPERIDONE TAB, OLANZAPINE TAB, ZIPRASIDONE CAP, QUETIAPINE TAB, ARIPIPRAZOLE TAB RISPERIDONE TAB, OLANZAPINE TAB, ZIPRASIDONE CAP, QUETIAPINE TAB, ARIPIPRAZOLE TAB CYCLOSPORINE CAP MOD OR GENGRAF CAP (GENERIC OF NEORAL) CYCLOSPORINE CAP MOD OR GENGRAF CAP (GENERIC OF NEORAL) CYCLOSPORINE SOL MODIFIED OR GENGRAF SOLN (GENERIC OF NEORAL) ESOMEPRAZOLE MAGNESIUM CAP DR, OMEPRAZOLE CAP, PANTOPRAZOLE TAB, DEXILANT CAP DR

4 4 NEXIUM GRA 2.5MG DR NEXIUM GRA 20MG DR NEXIUM GRA 40MG DR NEXIUM GRA 5MG DR PATADAY SOL 0.2% PHENADOZ SUP 12.5MG PHENADOZ SUP 25MG PHENERGAN SUP 12.5MG PHENERGAN SUP 25MG PHENERGAN SUP 50MG PRISTIQ TAB 100MG PRISTIQ TAB 25MG ESOMEPRAZOLE MAGNESIUM CAP DR, OMEPRAZOLE CAP, PANTOPRAZOLE TAB, DEXILANT CAP DR ESOMEPRAZOLE MAGNESIUM CAP DR, OMEPRAZOLE CAP, PANTOPRAZOLE TAB, DEXILANT CAP DR ESOMEPRAZOLE MAGNESIUM CAP DR, OMEPRAZOLE CAP, PANTOPRAZOLE TAB, DEXILANT CAP DR ESOMEPRAZOLE MAGNESIUM CAP DR, OMEPRAZOLE CAP, PANTOPRAZOLE TAB, DEXILANT CAP DR OLOPATADINE SOL 0.2% (GENERIC OF PATADAY) DESVENLAFAXINE TAB ER (GENERIC OF PRISTIQ), VENLAFAXINE HCL CAP ER 24HR, DULOXETINE CAP (20MG, 30MG, 60MG) DESVENLAFAXINE TAB ER (GENERIC OF PRISTIQ), VENLAFAXINE HCL CAP ER 24HR, DULOXETINE CAP (20MG, 30MG, 60MG)

5 5 PRISTIQ TAB 50MG PROGRAF CAP 0.5MG PROGRAF CAP 1MG PROGRAF CAP 5MG PROMETHAZINE SUP 12.5MG PROMETHAZINE SUP 25MG PROMETHAZINE SUP 50MG PROMETHEGAN SUP 12.5MG PROMETHEGAN SUP 25MG PROMETHEGAN SUP 50MG RAVICTI LIQ 1.1GM/ML DESVENLAFAXINE TAB ER (GENERIC OF PRISTIQ), VENLAFAXINE HCL CAP ER 24HR, DULOXETINE CAP (20MG, 30MG, 60MG) TACROLIMUS CAP (GENERIC OF PROGRAF) TACROLIMUS CAP (GENERIC OF PROGRAF) TACROLIMUS CAP (GENERIC OF PROGRAF) BUPHENYL TAB 500MG, SODIUM PHENYLBUTYRATE POWDER REVATIO SUS 10MG/ML SILDENAFIL TAB 20MG STRATTERA CAP 100MG STRATTERA CAP 10MG STRATTERA CAP 18MG STRATTERA CAP 25MG 100MG (GENERIC OF 10MG (GENERIC OF 18MG (GENERIC OF 25MG (GENERIC OF

6 6 STRATTERA CAP 40MG STRATTERA CAP 60MG STRATTERA CAP 80MG SUCRAID SOL 8500/ML SYMLINPEN 60 INJ 1000MCG SYMLNPEN 120 INJ 1000MCG TAZORAC CRE 0.1% TERBUTALINE INJ 1MG/ML TESTOSTERONE SOL 30MG/ACT TOBREX OIN 0.3% OP TOUJEO SOLO INJ 300IU/ML 40MG (GENERIC OF 60MG (GENERIC OF 80MG (GENERIC OF TAZAROTENE CRE 0.1% (GENERIC OF TAZORAC) VENTOLIN HFA, LEVALBUTEROL AER HFA, TERBUTALINE TAB 5MG, ALBUTEROL TAB TESTOSTERONE GEL 1%, ANDRODERM DIS, TESTOSTERONE CYPIONATE INJ, TESTOSTERONE ENANTHATE INJ ERYTHROMYCIN OIN OP, GENTAK OIN 0.3% OP, BACIT/POLYMY OIN OP, TOBRAMYCIN SOL 0.3% OP, BACITRACIN OIN OP BASAGLAR, LEVEMIR, TRESIBA TREANDA INJ 100MG BENDEKA TREANDA INJ 25MG BENDEKA TRIDERM CRE 0.1% TRIAMCINOLONE CRE 0.1% UPTRAVI TAB 1000MCG UPTRAVI TAB 1200MCG LETAIRIS TAB, ADCIRCA TAB, TRACLEER TAB, ADEMPAS LETAIRIS TAB, ADCIRCA TAB, TRACLEER TAB, ADEMPAS

7 7 UPTRAVI TAB 1400MCG UPTRAVI TAB 1600MCG UPTRAVI TAB 200/800MCG UPTRAVI TAB 200MCG UPTRAVI TAB 400MCG UPTRAVI TAB 600MCG UPTRAVI TAB 800MCG VALCYTE SOL 50MG/ML ZEPATIER TAB MG VALGANCICLOVIR SOLN 50MG/ML (GENERIC OF VALCYTE) SOVALDI plus DAKLINZA, SOVALDI If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug, you may ask Elderplan to make an exception to our coverage rules. To request a formulary or utilization restriction exception, please contact CVS/ Caremark at , 24 hours a day, 7 days a week. TTY/TDD users should call 711. Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, Elderplan is an HMO plan with Medicare and Medicaid contracts. Enrollment in Elderplan depends on contract renewal. The Formulary may change at any time. You will receive notice when necessary.

8 Elderplan, Inc. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Elderplan, Inc. does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. 8 ATTENTION: If you speak a non-english language or require assistance in ASL, language assistance services, free of charge, are available to you. Call (TTY: 711). (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). (Chinese) 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: 711). (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). (French Creole) ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (TTY: 711). (Korean) 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. (Italian) ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: 711). )Yiddish( אויפמערקזאם: אויב איר רעדט אידיש, זענען פארהאן פאר אייך שפראך הילף סערוויסעס פריי פון אפצאל. רופט (TTY: 711) (Bengali) লক ষ য কর ন যদ আপদন ব ল, কথ বলত প ত ন, হতল দন খ চ য় ভ ষ সহ য় পদ তষব উপলব ধ আত ফ ন কর ন (TTY: 711) (Polish) UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: 711). ) Arabic (ملحوظة: إذا كنت تتحدث لغة غير اإلنجليزية أو تحتاج إلى مساعدة في ASL فإن خدمات المساعدة اللغوية تتوافر لك مجانا (TTY: 711) اتصل برقم (French) ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS: 711). ( Urdu )خبردار: اگر آپ اردو بولتے ہيں تو آپ کو زبان کی مدد کی خدمات مفت ميں دستياب ہيں کال کريں (TTY: 711) (Tagalog) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711).

9 (Greek) ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε (TTY: 711). (Albanian) KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në (TTY: 711). 9