August 2016 Formulary Updates
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1 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 DAILY DOSE 8MG, 18MG - PA NUPLAZID - QL; PA ORFADIN SUSP 4MG/ML - PA TECENTRIQ - PA TRINTELLIX (formerly Brintellix) QL; ST TRUVADA TABS 100MG-150MG, 133MG-200MG, 167MG-250MG QL Prior Authorization Updates KUVAN Criteria Revised PRALUENT Criteria Revised REPATHA Criteria Revised LENVIMA Criteria Revised
2 July 2016 Formulary Updates AZATHIOPRINE INJ - PA PREDNISONE PAK 5MG, 10MG PROCTO-MED HC ROWEEPRA VANCOMYCIN INJ DOFETILIDE (EFFECTIVE JULY 8, 2016) DESCOVY QL EVOMELA - PA MENHIBRIX VENCLEXTA PA; QL VENCLEXTA STARTING PACK PA; QL CABOMETYX PA; QL (EFFECTIVE JULY 15, 2016) SPRITAM (EFFECTIVE JULY 20, 2016) Prior Authorization Update KUVAN Criteria Revised Step Updates
3 June 2016 Formulary Updates CARBAMAZEPINE ER TB12 100MG DOXEPIN HYDROCHLORIDE ROSUVASTATIN CALCIUM - QL ACTIVE OB DUET DHA 400 DUET DHA BALANCED MISC ELITE-OB LOTEMAX MARNATAL-F MARQIBO - PA OB COMPLETE TABS ODEFSEY - QL PRENATE ENHANCE PRENATE RESTORE PRENATE STAR PROVIDA OB SELECT-OB+DHA TARON-BC VITAFOL GUMMIES VITAFOL ULTRA VITAFOL-NANO VITAFOL-OB VITAFOL-OB+DHA VITATRUE VP-CH-PLUS VP-GGR-B6 PRENATAL Prior Authorization Updates FASLODE - Criteria Revised IBRANCE - Criteria Revised PRALUENT - Criteria Revised REPATHA - Criteria Revised Step Updates
4
5 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 - ST REPATHA - QL; PA REPATHA SURECLICK - QL; PA VP-HEME ONE VRAYLAR CAPS - QL; ST VRAYLAR PACK - QL; ST Prior Authorization Updates HARVONI - Criteria Revised SOVALDI - Criteria Revised OPDIVO - Criteria Revised
6 April 2016 Formulary Updates FLUOR-A-DAY SOLN FLUORITAB SOLN IMATINIB MESYLATE TABS 100MG - QL; PA IMATINIB MESYLATE TABS 400MG - QL; PA KAITLIB FE VIENVA EDARBI - QL EDARBYCLOR - QL Prior Authorization Updates ARISTADA - PA removed EVZIO - PA removed MODERIBA TABS - PA removed NARCAN - PA removed RIBAVIRIN - PA removed TESTOSTERONE CYPIONATE INJ - PA removed TESTOSTERONE ENANTHATE IN - PA removed INVEGA SUSTENNA - QL removed ELIQUIS TABS 5 MG - QL 74/30 days REXULTI
7 March 2016 Formulary Updates BEKYREE NORGESTIMATE/ETHINYL ESTRADIOL TRI-LO-ESTARYLLA TRI-LO-SPRINTEC TRINESSA LO ALECENSA - QL; PA BENDEKA ENTRESTO - QL; PA ENVARSUS XR - PA FERRIPROX SOLN 100MG/ML - PA IRESSA - QL; PA NARCAN - PA PORTRAZZA - PA PRADAXA CAPS 110MG - QL STRIVERDI RESPIMAT - QL TRESIBA FLEXTOUCH ULORIC TABS - ST Prior Authorizations Updates
8 February 2016 Formulary Updates ALA CORT CREA 1% ARIPIPRAZOLE ODT TBDP 10MG - QL ARIPIPRAZOLE ODT TBDP 15MG - QL BLISOVI 24 FE TABS 20MCG; 75MG; 1MG BLISOVI FE 1/20 TABS 20MCG; 75MG; 1MG BUDESONIDE SUSP 1MG/2ML - PA CEFAZOLIN CEFTRIAXONE SODIUM INJ 100GM DUTASTERIDE/TAMSULOSIN HYDROCHLORIDE CAPS 0.5MG; 0.4M - QL FLORIVA CHEW LINEZOLID SUSR 100MG/5ML - QL; PA MICROGESTIN 24 FE MOLINDONE HYDROCHLORIDE TABS 10MG - QL MOLINDONE HYDROCHLORIDE TABS 25MG - QL MOLINDONE HYDROCHLORIDE TABS 5MG - QL OLOPATADINE SOLN 0.1% REPAGLINIDE/METFORMIN HYDROCHLORIDE TABS 500MG; 1MG - QL REPAGLINIDE/METFORMIN HYDROCHLORIDE TABS 500MG; 2MG - QL SPS COTELLIC TABS 20MG - QL; PA DARZALEX SOLN - PA EMPLICITI SOLR - PA FERRIPROX TABS 500MG - PA GENVOYA TABS 150MG; 150MG; 200MG; 10MG - QL GLEOSTINE CAPS 5MG NINLARO CAPS 2.3MG - QL; PA NINLARO CAPS 3MG - QL; PA NINLARO CAPS 4MG - QL; PA OB COMPLETE GOLD PREFERA OB TABS TAGRISSO TABS 40MG - QL; PA TAGRISSO TABS 80MG - QL; PA VITAFOL FE
9 Prior Authorizations Updates ONDANSETRON ODT TBDP 4MG - PA removed DIAZEPAM TABS 10MG - PA removed DIAZEPAM TABS 2MG - PA removed DIAZEPAM TABS 5MG - PA removed ONDANSETRON HCL TABS 4MG - PA removed DIAZEPAM SOLN 1MG/ML - PA removed ONDANSETRON HCL TABS 24MG - PA removed ONDANSETRON HCL SOLN 4MG/5ML - PA removed ONDANSETRON HCL TABS 8MG - PA removed ONDANSETRON ODT TBDP 8MG - PA removed INVEGA TRINZA - QL removed ANORO ELLIPTA AEPB 62.5MCG/INH; 25MCG/INH - ST removed AURYXIA TABS 210MG - ST removed BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 1/2" MISC - ST removed BD INSULIN SYRINGE ULTRAFINE/1ML/31G X 5/16" MISC - ST removed BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16" MISC - ST removed ADVAIR DISKUS AEPB 100MCG/DOSE; 50MCG/DOSE - ST removed ADVAIR DISKUS AEPB 250MCG/DOSE; 50MCG/DOSE - ST removed ADVAIR DISKUS AEPB 500MCG/DOSE; 50MCG/DOSE - ST removed ADVAIR HFA AERO 45MCG/ACT; 21MCG/ACT - ST removed ADVAIR HFA AERO 115MCG/ACT; 21MCG/ACT - ST removed ADVAIR HFA AERO 230MCG/ACT; 21MCG/ACT - ST removed
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Acyclovir Ointment Mercy Care Plan acyclovir ointment 5 % external Requires use of oral Acyclovir 1 Adcirca ADCIRCA TABLET 20 MG ORAL Requires use of Sildenafil 2 Albenza ALBENZA TABLET 200 MG ORAL Requires
New Generics: Specialty Network: Retail Pharmacies Dispensing Specialty Products
SUPPORTING OUR PROVIDER PARTNERS THROUGH COMMUNICATION AND COLLABORATION. DATE JANUARY 2016 ISSUE 1 HELPFUL NUMBERS FOR PROVIDERS Magellan: 1-800-846-7971 Bin: 016523 Processor control: 747 HELPFUL NUMBERS
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
Plan Year 2018 Prior Authorization (PA) Criteria
Plan Year 2018 Prior Authorization (PA) Criteria Prior Authorization: Commonwealth Care Alliance requires you (or your physician) to get prior authorization for certain drugs. This means that you will
Specialty Drugs. The specialty drug list below is effective June 5, 2018 and is subject to change at any time.
Specialty Drugs The following is a list of medications that are considered specialty drugs. Specialty drugs include self-administered injectables, medications that are high cost, and/or medications that
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
ALABAMA MEDICAID AGENCY Prenatal Vitamins Preferred Status
Prenatal Vitamins Status Effective January 4, 2010, the prenatal vitamins were included in the Alabama Medicaid Drug Program. The list below includes the current preferred status of the covered prenatal
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.
Drug Quantity Limits
Tier 1 Formulary Drug Quantity Limits 2016 Updated: 10/25/2016 Effective: 11/01/2016 What are Quantity Limits? For certain drugs, we limit the amount of the drug that you can have by limiting how much
Quarterly pharmacy formulary change notice
Provider update This is an update about information in the provider manual. For access to the latest provider manual, go online to https://providers.amerigroup.com. Quarterly pharmacy formulary change