Medicare Part D 2012 Formulary Changes Service To Senior and Total Fit
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1 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, quantity limits and/or step therapy restrictions or move a drug to a higher cost-sharing tier, we will notify you of the change at least 60 days before the date that the change becomes effective. However, if the U.S. Food and Drug Administration (FDA) determines a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary. The table below outlines changes made to our formulary throughout FORMULARY ADDITIONS UPDATE AS OF SEPTEMBER 1, 2012: Formulary additions, reductions in preferred or tiered cost-sharing status, or removal of to an existing formulary drug JANUMET XR TAB SITAGLIPTIN and JANUMET XR TAB SITAGLIPTIN and JANUMET XR TAB MG SITAGLIPTIN and JENTADUETO TAB LINAGLIPTIN and JENTADUETO TAB LINAGLIPTIN and JENTADUETO TAB LINAGLIPTIN and VICTOZA INJ 18MG/3ML LIRAGLUTIDE Addition 9/1/ Prior Authorization 1
2 ZIOPTAN DRO % TAFLUPROST Addition 9/1/ QL (30 per 30 days) BESIVANCE SUS0.6% BESIFLOXACIN Addition 8/15/ NEVANAC SUS0.1% NEPAFENAC Addition 8/15/ DUREZOL EMU0.05% DIFLUPREDNATE Addition 8/15/ MONTELUKAST CHW4MG SINGULAIR Addition 8/14/ QL (30 per 30 days) MONTELUKAST CHW5MG SINGULAIR Addition 8/14/ QL (30 per 30 days) MONTELUKAST TAB10MG SINGULAIR Addition 8/14/ QL (30 per 30 days) ZIOPTAN DRO0.0015% TAFLUPROST Addition 8/13/ QL (30 per 30 days) COMBIVENT AER RESPIMAT IPRATROPIUM BROMIDE and ALBUTEROL Addition 8/1/ NEVIRAPINE TAB 200MG VIRAMUNE Addition 8/1/ ZIPRASIDONE CAP 20MG GEODON Addition 8/1/ QL (60 per 30 days) ZIPRASIDONE CAP 40MG GEODON Addition 8/1/ QL (60 per 30 days) ZIPRASIDONE CAP 60MG GEODON Addition 8/1/ QL (60 per 30 days) ZIPRASIDONE CAP 80MG GEODON Addition 8/1/ QL (60 per 30 days) ANDROGEL GEL 1.62% TESTOSTERONE Addition 7/1/ QL (150 per 30 days) LATUDA TAB 20MG LURASIDONE Addition 7/1/ QL (60 per 30 days) VIIBRYD KIT VILAZODONE Addition 7/1/ QL (30 per 30 days) Remove Step and Lower 6/20/2012 ATORVASTATIN TAB 10MG LIPITOR Copay 1 QL (30 per 30 days) Remove Step and Lower 6/20/2012 ATORVASTATIN TAB 20MG LIPITOR Copay 1 QL (30 per 30 days) Remove Step and Lower 6/20/2012 ATORVASTATIN TAB 40MG LIPITOR Copay 1 QL (30 per 30 days) 2
3 Remove Step and Lower 6/20/2012 ATORVASTATIN TAB 80MG LIPITOR Copay 1 QL (30 per 30 days) TRADJENTA TAB 5MG LINAGLIPTIN Addition 6/5/ QL (30 per 30 days) DALIRESP TAB 500MCG ROFLUMILAST Addition 6/5/ QL (30 per 30 days) TOTAL PARENTERAL 6/1/2012 PROSOL INJ 20% NUTRITION Addition 5 QUETIAPINE TAB 100MG SEROQUEL Addition 6/1/ QL (120 per 30 days) QUETIAPINE TAB 200MG SEROQUEL Addition 6/1/ QL (90 per 30 days) QUETIAPINE TAB 25MG SEROQUEL Addition 6/1/ QL (120 per 30 days) QUETIAPINE TAB 300MG SEROQUEL Addition 6/1/ QL (90 per 30 days) QUETIAPINE TAB 400MG SEROQUEL Addition 6/1/ QL (60 per 30 days) QUETIAPINE TAB 50MG SEROQUEL Addition 6/1/ QL (120 per 30 days) POTIGA TAB 200MG EZOGABINE Addition 6/1/ POTIGA TAB 300MG EZOGABINE Addition 6/1/ POTIGA TAB 400MG EZOGABINE Addition 6/1/ POTIGA TAB 50MG EZOGABINE Addition 6/1/ CLOPIDOGREL TAB 75MG PLAVIX Addition 5/22/ QL (30 per 30 days) ERIVEDGE CAP 150MG VISMODEGIB Addition 5/1/ Prior Authorization INLYTA TAB 1MG AXITINIB Addition 5/1/ Prior Authorization INLYTA TAB 5MG AXITINIB Addition 5/1/ Prior Authorization VIREAD POW 40MG/GM VIREAD TAB 150MG VIREAD TAB 200MG TENOFOVIR DISOPROXIL FUMARATE Addition 5/1/ TENOFOVIR DISOPROXIL FUMARATE Addition 5/1/ TENOFOVIR DISOPROXIL FUMARATE Addition 5/1/
4 VIREAD TAB 250MG TENOFOVIR DISOPROXIL FUMARATE Addition 5/1/ CAPRELSA TAB 100MG VANDETANIB Addition 4/1/ QL (60 per 30 days) CAPRELSA TAB 300MG VANDETANIB Addition 4/1/ QL (30 per 30 days) CLOBETASOL AER 0.05% CLOBETASOL Addition 4/1/ CLOBETASOL LOT 0.05% CLOBETASOL Addition 4/1/ CLOBETASOL SHA 0.05% CLOBETASOL Addition 4/1/ FEXOFENADINE TAB 180MG ALLEGRA Deletion 4/1/ QL (30 per 30 days) FEXOFENADINE TAB 30MG ALLEGRA Deletion 4/1/ QL (60 per 30 days) FEXOFENADINE TAB 60MG ALLEGRA Deletion 4/1/ QL (60 per 30 days) MENEST TAB 0.3MG ESTERIFIED ESTROGENS Addition 4/1/ MENEST TAB 0.625MG ESTERIFIED ESTROGENS Addition 4/1/ MENEST TAB 1.25MG ESTERIFIED ESTROGENS Addition 4/1/ MENEST TAB 2.5MG ESTERIFIED ESTROGENS Addition 4/1/ ALFUZOSIN TAB 10MG UROXATRAL Addition 3/1/ ARCAPTA CAP 75MCG INDACATEROL Addition 3/1/ QL (30 per 30 days) BOOSTRIX INJ TETANUS TOXOID, Addition 3/1/ DIPHTHERIA TOXOID, AND ACELLULAR PERTUSSIS VACCINE COMPLERA TAB EMTRICITABINE, RILPIVIRINE, and TENOFOVIR Addition 3/1/ QL (30 per 30 days) DILTIAZEM CAP 180MG/24 DILTIAZEM Addition 3/1/
5 DOCEFREZ INJ 20MG DOCETAXEL Addition 3/1/ Prior auth DOCEFREZ INJ 80MG DOCETAXEL Addition 3/1/ Prior auth FLUCYTOSINE CAP 250MG ANCOBON Addition 3/1/ FLUCYTOSINE CAP 500MG ANCOBON Addition 3/1/ JAKAFI TAB 10MG RUXOLITINIB Addition 3/1/ Prior auth JAKAFI TAB 15MG RUXOLITINIB Addition 3/1/ Prior auth JAKAFI TAB 20MG RUXOLITINIB Addition 3/1/ Prior auth JAKAFI TAB 25MG RUXOLITINIB Addition 3/1/ Prior auth JAKAFI TAB 5MG RUXOLITINIB Addition 3/1/ Prior auth LAMIVUDINE TAB 150MG EPIVIR Addition 3/1/ LAMIVUDINE TAB 300MG EPIVIR Addition 3/1/ NULOJIX INJ 250MG BELATACEPT Addition 3/1/ Prior auth OLANZAPINE TAB 10MG ZYPREXA Addition 3/1/ QL (30 per 30 days) OLANZAPINE TAB 10MG ODT ZYPREXA Addition 3/1/ QL (30 per 30 days) OLANZAPINE TAB 15MG ZYPREXA Addition 3/1/ QL (30 per 30 days) OLANZAPINE TAB 15MG ODT ZYPREXA Addition 3/1/ QL (30 per 30 days) OLANZAPINE TAB 2.5MG ZYPREXA Addition 3/1/ QL (30 per 30 days) OLANZAPINE TAB 20MG ZYPREXA Addition 3/1/ QL (30 per 30 days) OLANZAPINE TAB 20MG ODT ZYPREXA Addition 3/1/ QL (30 per 30 days) OLANZAPINE TAB 5MG ZYPREXA Addition 3/1/ QL (30 per 30 days) OLANZAPINE TAB 5MG ODT ZYPREXA Addition 3/1/ QL (30 per 30 days) OLANZAPINE TAB 7.5MG ZYPREXA Addition 3/1/ QL (30 per 30 days) PHOSLYRA SOL CALCIUM ACETATE Addition 3/1/ QL (1800 per 30 days) TAMIFLU SUS 6MG/ML OSELTAMIVIR Addition 3/1/ QL ( 900 per 180 days) VIRAMUNE XR TAB NEVIRAPINE Addition 3/1/ QL (30 per 30 days) XALKORI CAP 200MG CRIZOTINIB Addition 3/1/ Prior auth XALKORI CAP 250MG CRIZOTINIB Addition 3/1/ Prior auth XARELTO TAB 10MG RIVAROXABAN Addition 3/1/ QL (30 per 30 days),prior Auth 5
6 XARELTO TAB 15MG RIVAROXABAN Addition 3/1/ QL (30 per 30 days),prior Auth XARELTO TAB 20MG RIVAROXABAN Addition 3/1/ QL (30 per 30 days),prior Auth YERVOY INJ 50MG IPILIMUMAB Addition 3/1/ Prior auth ZELBORAF TAB 240MG VEMURAFENIB Addition 3/1/ Prior auth ZENPEP CAP 25000UNT PANCRELIPASE Addition 3/1/ ZENPEP CAP 3000UNIT PANCRELIPASE Addition 3/1/ ZOMETA INJ 4MG/100 ZOLEDRONIC ACID Addition 3/1/ Prior auth DEXAMETHASON TAB 2MG DEXAMETHASONE Addition 2/1/ ACTOPLUS MET TAB 15/500MG ACTOPLUS MET TAB 15/850MG METFORMIN PIOGLITAZONE METFORMIN PIOGLITAZONE 4 to 3 4 to 3 ACTOS TAB 15MG PIOGLITAZONE 4 to 3 ACTOS TAB 30MG PIOGLITAZONE 4 to 3 ACTOS TAB 45MG PIOGLITAZONE 4 to 3 ADVAIR DISKU AER 100/50 FLUTICASONE and 4 to 3 ADVAIR DISKU AER 250/50 FLUTICASONE and 4 to 3 ADVAIR DISKU AER 500/50 FLUTICASONE and 4 to 3 ADVAIR HFA AER 115/21 FLUTICASONE and 4 to 3 1/1/ QL (90 per 30 days) 1/1/ QL (90 per 30 days) 1/1/ QL (12 per 30 days) 6
7 ADVAIR HFA AER 230/21 FLUTICASONE and 1/1/ QL (12 per 30 days) 4 to 3 ADVAIR HFA AER 45/21 FLUTICASONE and 1/1/ QL (12 per 30 days) 4 to 3 AMLOD/BENAZP CAP 10-40MG LOTREL Addition 1/1/ QL (30 per 30 days) AMLOD/BENAZP CAP 5-40MG LOTREL Addition 1/1/ QL (30 per 30 days) ATORVASTATIN TAB 10MG LIPITOR Addition 1/1/ QL (30 per 30 days), Step Therapy ATORVASTATIN TAB 20MG LIPITOR Addition 1/1/ QL (30 per 30 days), Step Therapy ATORVASTATIN TAB 40MG LIPITOR Addition 1/1/ QL (30 per 30 days), Step Therapy ATORVASTATIN TAB 80MG LIPITOR Addition 1/1/ QL (30 per 30 days), Step Therapy AVANDAMET TAB MG METFORMIN AVANDAMET TAB 2-500MG METFORMIN AVANDAMET TAB MG METFORMIN AVANDAMET TAB 4-500MG METFORMIN AVANDARYL TAB 4-1MG GLIMEPIRIDE / moved from 4 to 3 4 to 3 4 to 3 4 to 3 4 to 3 7
8 AVANDARYL TAB 4-2MG GLIMEPIRIDE / 4 to 3 AVANDARYL TAB 4-4MG GLIMEPIRIDE / 4 to 3 AVANDARYL TAB 8-2MG GLIMEPIRIDE / 4 to 3 AVANDARYL TAB 8-4MG GLIMEPIRIDE / 4 to 3 AVANDIA TAB 2MG 4 to 3 AVANDIA TAB 4MG 4 to 3 AVANDIA TAB 8MG 4 to 3 BRIMONIDINE SOL 0.15% ALPHAGAN P Addition 1/1/ BYETTA INJ 10MCG EXENATIDE 1/1/ Prior auth 4 to 3 BYETTA INJ 5MCG EXENATIDE 1/1/ Prior auth 4 to 3 COMBIVENT AER ALBUTEROL/IPRATROPIU Addition 1/1/ M DETROL LA CAP 2MG TOLTERODINE 4 to 3 DETROL LA CAP 4MG TOLTERODINE 4 to 3 DETROL TAB 1MG TOLTERODINE 4 to 3 DETROL TAB 2MG TOLTERODINE 4 to 3 8
9 DIOVAN HCT TAB 160/12.5 VALSARTAN and HYDROCHLOROTHIAZIDE 4 to 3 DIOVAN HCT TAB 160/25MG VALSARTAN and HYDROCHLOROTHIAZIDE 4 to 3 DIOVAN HCT TAB 320/12.5 VALSARTAN and HYDROCHLOROTHIAZIDE 4 to 3 DIOVAN HCT TAB 320/25MG VALSARTAN and HYDROCHLOROTHIAZIDE 4 to 3 DIOVAN HCT TAB 80/12.5 VALSARTAN and HYDROCHLOROTHIAZIDE 4 to 3 DIOVAN TAB 160MG VALSARTAN 4 to 3 DIOVAN TAB 320MG VALSARTAN 4 to 3 DIOVAN TAB 40MG VALSARTAN 4 to 3 DIOVAN TAB 80MG VALSARTAN 4 to 3 LEVOFLOXACIN TAB 250MG LEVAQUIN Addition 1/1/ QL (14 per 14 days) LEVOFLOXACIN TAB 500MG LEVAQUIN Addition 1/1/ QL (14 per 14 days) LEVOFLOXACIN TAB 750MG LEVAQUIN Addition 1/1/ QL (14 per 14 days) LITHIUM CARB CAP 600MG LITHIUM CARBONATE Addition 1/1/ LITHIUM CARB TAB 300MG LITHIUM CARB Addition 1/1/ NAPROXEN TAB 500MG NAPROXEN Addition 1/1/
10 NIASPAN TAB 1000 ER NIACIN 4 to 3 NIASPAN TAB 500MG ER NIACIN 4 to 3 NIASPAN TAB 750MG ER NIACIN 4 to 3 POT CHLORIDE CAP 8MEQ ER MICRO-K Addition 1/1/ RESTASIS EMU 0.05% CYCLOSPORINE Remove Prior 1/1/ QL (60 per 30 days) Auth SEREVENT DIS AER 50MCG 4 to 3 SYLATRON KIT 296MCG PEGINTERFERON Addition 1/1/ Prior auth SYLATRON KIT 444MCG PEGINTERFERON Addition 1/1/ Prior auth SYLATRON KIT 888MCG PEGINTERFERON Addition 1/1/ Prior auth SYMLIN INJ 600MCG PRAMLINTIDE ACETATE 1/1/ QL (20 per 30 days) 4 to 3 SYMLINPEN 60 INJ 1000MCG PRAMLINTIDE ACETATE 1/1/ QL (11 per 30 days) 4 to 3 SYMLNPEN 120 INJ 1000MCG PRAMLINTIDE ACETATE 1/1/ QL (11 per 30 days) 4 to 3 TASIGNA CAP 150MG NILOTINIB Addition 1/1/ Prior auth ZOSTAVAX INJ ZOSTER VACCINE LIVE 4 to 3 1/1/
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