November 2016 Formulary Updates
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- Juliet Wilkinson
- 6 years ago
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1 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 25% CUTTER LEMON EUCALYPTUS LIQD CUTTER SKINSATIONS LIQD 7% NATRAPEL 12-HOUR TICK & INSECT REPELLENT CONTINUOUS SPRAY AERO 20% OFF ACTIVE AERO 15% OFF DEEP WOODS 25% OFF DEEP WOODS DRY AERO 25% OFF SMOOTH & DRY AERO 15% REPEL SPORTSMEN AERO 25% REPEL SPORTSMEN MAX AERO 40% REPEL SPORTSMEN MAX LOTN 40% SAWYER PREMIUM INSECT REPELLENT LIQD 20% ULTRATHON INSECT REPELLENT LOTN 34.34% *due to late change, these additions will not be reflected in the November 1 effective formulary posting or web search tool but will be on the December 1 documents.
2 October 2016 Formulary Updates LEVOLEUCOVORIN INJ 50MG MESALAMINE DR MORGIDOX 1X 50MG NILUTAMIDE BLEO 15K PA EPCLUSA PA; QL ORFADIN Criteria Updated HUMIRA Criteria Updated
3 September 2016 Formulary Updates ARMODAFINIL TAB QL; PA HYDROXYPROGESTERONE CAPROATE INJ PA FYCOMPA SUSPENSION QL; PA JARDIANCE TAB - QL JENTADUETO XR TAB REPATHA PUSHTRONEX SYSTEM QL; PA SYNJARDY TAB - QL TIVICAY TABS 10MG, 25MG - QL JANUMET TAB QL removed JANUMET XR TAB QL removed JANUVIA TAB QL removed
4 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 TRINTELLIX (formerly Brintellix) QL; ST TRUVADA TABS 100MG-150MG, 133MG-200MG, 167MG-250MG QL KUVAN Criteria Revised PRALUENT Criteria Revised REPATHA Criteria Revised LENVIMA Criteria Revised
5 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 QL; PA VENCLEXTA STARTING PACK - QL; PA CABOMETYX PA; QL (EFFECTIVE JULY 15, 2016) SPRITAM (EFFECTIVE JULY 20, 2016) KUVAN - Criteria Revised Step Updates
6 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 REPATHA - QL; PA REPATHA SURECLICK - QL; PA FASLODEX; Criteria Revised IBRANCE; Criteria Revised PRALUENT; Criteria Revised REPATHA; Criteria Revised Step Updates
7
8 May 2016 Formulary Updates ASCOMP/COD - QL; PA FYAVOLV 5MCG; 1MG - PA METOPROLOL TABS 37.5MG, 75MG REPATHA - QL; PA REPATHA SURECLICK - QL; PA CIPRODEX LETAIRIS - QL; PA OFEV - QL; PA OTREXUP - ST PRALUENT - QL; PA RASUVO - ST VP-HEME ONE VRAYLAR CAPS - QL; ST VRAYLAR PACK - QL; ST HARVONI; Criteria Revised SOVALDI; Criteria Revised OPDIVO; Criteria Revised
9 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 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
10 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
11 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; 0.4MG - 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
12 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
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
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Acyclovir Ointment. Aetna Better Health Pennsylvania. Products Affected. acyclovir ointment 5 % external Details. Criteria
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Network Health Insurance Corporation NetworkCares Step Therapy Last Updated: 7/2017 ANTICONVULSANT THERAPY Aptiom 200 mg tablet Aptiom 400 mg tablet Aptiom 600 mg tablet Aptiom 800 mg tablet Banzel 200
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Ultimate Health Plans (HMO)
Ultimate Health Plans (HMO) abacavir-lamivudine 600-300 mg abacavir-lamivudine-zidov tab ACTEMRA 162 MG/0.9 ML SYRINGE ADCIRCA 20 MG TABLET ADEMPAS (0.5 MG TABLET, 1 MG TABLET, 1.5 MG TABLET, 2 MG TABLET,
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March 2017 Effective Date Brand Name EVZIO erythromycin ethylsuccinate naloxone hcl Generic Name erythromycin ethylsuccinate Type of Change Previous Value New Value ofloxacin ofloxacin NAMZARIC NAMZARIC
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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/fl. Quarterly pharmacy formulary change
Quarterly pharmacy formulary change notice
Quarterly pharmacy formulary change notice The formulary changes listed in the table below were reviewed and approved at our second quarter 2018 Pharmacy and Therapeutics Committee meeting. Effective October