Formulary Updates to DHMP Commercial Plans (POS/DMC/DMC-E/CSA/DERP/DPPA & DHMO:CSA/DERP/DPPA)

Transcription

1 1 Formulary Updates to DHMP Commercial Plans (POS/DMC/DMC-E/CSA/DERP/DPPA & DHMO:CSA/DERP/DPPA) Denver Health Medical Plan (DHMP) may add or remove drugs from the formulary or make changes to restrictions on formulary drugs during the year. If DHMP removes drugs from the formulary, or adds a restriction to an existing formulary drug, such as prior authorization, quantity limits and/or step therapy, [and/or moves a drug to a higher cost-sharing tier], DHMP will notify you of the change at least 60 days before the date that the change becomes effective. If the Food and Drug Administration (FDA) deems a drug on the formulary to be unsafe, or the drug s manufacturer removes the drug from the market, DHMP will immediately remove the drug from the formulary. The table below outlines previous and/or recent changes to the formulary. The newest updates are highlighted in yellow. For questions or if you would like more information related to these changes please call the DHMP Pharmacy Services Department at or FORMULARY ABBREVIATIONS (Explanations can be found on the website in the DHMP Commercial Formulary and Pharmaceutical Management Procedures) DISC = Lowest Copay (note: DISC = 1 for the DHMO plan); LA = Limited Access (must be filled at DH Pharmacy or PA Required); PA = Prior Authorization; PREV = Preventative Medication; QL = Quantity Limit; ST = Step Therapy Chantix Starting and Continuing Paks ; Limited Access Restriction Added Clinical Reevaluation N/A N/A LA, QL 10/01/2015 Lantus Solostar Pens Addition Addition N/A 2 QL 10/01/2015 Levemir Flextouch Pens Addition Addition N/A 2 QL 10/01/2015 Tizanidine Tablets Addition Addition N/A 1 LA 10/01/2015 Lidocaine Extended- Release Patches Zolpidem Extended- Release Tablets Risedronate 5 mg, 30 mg and 35 mg Tablets Generic Available for Actonel Cost Reevaluation N/A 1 QL 10/01/2015 Cost Reevaluation N/A 1 LA, QL 10/01/2015 Generic N/A 1 07/01/2015

2 2 Aripiprazole Tablets Generic Available for Abilify Generic N/A 1 LA, PA, QL 07/01/2015 PEG 3350/Bisacodyl/ Generic Available for Generic N/A 1 07/01/2015 Sodium Chloride/Sodium Bicarbonate/Potassium Chloride Halflytely-Bisacodyl True Metrix Air Addition Addition N/A 1 QL 07/01/2015 Glucometer True Metrix Air Test Addition Addition N/A 1 QL 07/01/2015 Strips True Metrix Air Control Addition Addition N/A 1 QL 07/01/2015 Solution Gynol II Spermicide Jelly Addition Addition N/A PREV 07/01/2015 FC2 Female Condom Addition Addition N/A PREV 07/01/2015 FemCap Cervical Cap Addition Addition N/A PREV 07/01/2015 Today Contraceptive Addition Addition N/A PREV 07/01/2015 Sponge Paragard IUD Addition Addition N/A PREV 07/01/2015 Nexplanon Implantable Addition Addition N/A PREV 07/01/2015 Rod Buprenorphine/Naloxone Addition Addition N/A 1 LA, QL 07/01/2015 Sublingual Tablets Guanfacine Extended- Addition Addition N/A 1 LA, QL, ST 07/01/2015 Release Tablets Xifaxan Tablets Addition Addition N/A 3 LA, QL, ST 07/01/2015 Doxycycline Capsules/Tablets ; Limited Access Restriction ; Quantity Clinical Reevaluation N/A N/A QL 04/01/2015

3 3 Limit Restriction Added Valsartan Tablets Addition Addition N/A 1 04/01/2015 Valsartan/HCTZ Tablets Addition Addition N/A 1 04/01/2015 Amlodipine/Benazepril Tablets Addition Addition N/A 1 04/01/2015 Janumet Tablets Addition Addition N/A 3 LA 04/01/2015 Omega-3 Acid Ethyl Esters Capsules Addition Addition N/A 1 LA, QL 04/01/2015 Harvoni Tablets Addition Addition N/A 4 LA, QL, PA 04/01/2015 Esomeprazole Capsules Generic Available for Nexium Incivek Tablets Deletion Manufacturer Discontinued Estradiol Twice-weekly Patches Valganciclovir Tablets Acyclovir, albuterol nebulizer soln., albuterol tablets and syrup, amoxicillin, antipyrine/benzocaine otic, atropine 1% op. soln., baclofen, benztropine, carbamazepine, cephalexin, chlorhexidine Generic N/A 1 LA, QL, ST 04/01/2015 Harvoni 4 LA, PA, QL 04/01/2015 Generic Available for Alora Generic N/A 1 04/01/2015 Generic Available for Valcyte Change from Discount (DISC) to 1 Generic N/A N/A LA 04/01/2015 Cost Reevaluation N/A 1 01/01/2015

4 4 gluconate, ciprofloxacin, cyclobenzaprine, dexamethasone, dicyclomine, digoxin, erythromycin 0.5% op. oint., fluconazole 150 mg tab, fluocinonide cream, gentamicin 0.3% op. soln., hydrocortisone cream and oint., ibuprofen, indomethacin, ipratropium bromide nebulizer soln., isoniazid, isosorbide mononitrate ER, lactulose, levobunolol 0.5% op. soln., levothyroxine, lidocaine viscous, meloxicam, metoclopramide, naproxen, neo/polymyx b/dexam op., nystatin cream, penicillin vk, polymyxin/tmp op. soln., prednisone, prochlorperazine, promethazine tabs and syrup, promethazine DM,

5 5 ranitidine, SMZ/TMP, thioridazine, timolol maleate op. soln., tobramycin 0.3% op. soln., triamcinolone cream and oint., trihexyphenidyl Levitra ; Age Restriction Added Clinical Reevaluation N/A N/A LA, QL 01/01/2015 Ventolin HFA inhaler Change from 1 to 2 Cost Reevaluation N/A 2 QL 01/01/2015 Celecoxib Capsules Generic Available for Generic N/A 1 LA, PA, QL 01/01/2015 Celebrex Halflytely-Bisacodyl Change from Preventative Cost Reevaluation N/A 2 01/01/2015 (PREV) to 2 Auvi-Q Deleted Cost Reevaluation Epinephrine Auto- N/A 01/01/2015 Injector Twinject Deleted Cost Reevaluation Epinephrine Auto- N/A 01/01/2015 Injector EpiPen Change from 2 to 3 Cost Reevaluation Epinephrine Auto- 3 LA, QL 01/01/2015 Injector EpiPen Jr Change from 2 to 3 Cost Reevaluation Epinephrine Auto- 3 LA, QL 01/01/2015 Injector Avonex Clinical Reevaluation N/A N/A LA, QL 01/01/2015 Betaseron Clinical Reevaluation N/A N/A LA, QL 01/01/2015 Leflunomide Tablets Addition Addition N/A 1 LA, QL 01/01/2015

6 6 Enbrel Addition Addition N/A 4 LA, QL, ST 01/01/2015 Humira Addition Addition N/A 4 LA, QL, ST 01/01/2015 Rebif Addition Addition N/A 4 LA, QL 01/01/2015 Duloxetine Capsules Addition Addition N/A 1 LA, QL, ST 01/01/2015 Nexium Capsules Addition Addition N/A 3 LA, QL, ST 01/01/2015 Sovaldi Tablets Addition Addition N/A 4 LA, PA, QL 01/01/2015 Doxycycline Change from Discount Cost Reevaluation Minocycline 1 LA, ST 01/01/2015 Capsules/Tablets (DISC) to 1; Step Therapy Restriction Added; Limited Access Restriction Added Ella Tablets Addition Addition N/A PREV 10/01/2014 Tivicay Tablets Addition Addition N/A 3 LA, QL, ST 10/01/2014 Stribild Tablets Addition Addition N/A 3 LA, ST 10/01/2014 Minocycline Capsules Limited Access Restriction Cost Reevaluation N/A 1 QL 10/01/2014 Fenofibrate 54 mg, 134 Addition Addition N/A 1 QL, ST 07/01/2014 mg, 160 mg Levemir Vials Addition Addition N/A 2 QL 07/01/2014 Lidocaine Extended- Addition Addition N/A 1 QL, ST 07/01/2014 Release Patches Nicotine Lozenges Addition Addition N/A 1 07/01/2014 Midazolam 1mg/ml and Addition Addition N/A 1 LA, QL 07/01/2014 5mg/ml Vials Rifabutin Capsules Generic Available for Generic N/A 1 07/01/2014 Mycobutin Budesonide 32 mcg Nasal Generic Available for Generic N/A 1 QL 07/01/2014

7 7 Spray Risedronate 150 mg Tablets Testosterone Gel Rhinocort Aqua Generic Available for Actonel Generic Available for Testim Gel Generic N/A 1 07/01/2014 Generic N/A 1 LA 07/01/2014 Glimepiride Tablets Addition Addition N/A 1 04/01/2014 Capecitabine Tablets Generic Available for Xeloda Generic N/A 1 LA, PA 04/01/2014 Abacavir/Lamivudine/ Zidovudine Tablets Tolterodine Extended- Release Capsules Chantix Tablets Generic Available for Trizivir Generic N/A 1 LA 04/01/2014 Generic Available for Detrol LA Step Therapy Changed to Previous Failure of Bupropion or Nicotine Replacement Therapy Generic N/A 1 04/01/2014 Clinical Reevaluation N/A N/A ST, QL 04/01/2014 Progesterone Capsules Addition Addition N/A 1 QL 01/01/2014 Pramipexole Tablets Addition Addition N/A 1 01/01/2014 Tobramycin 0.3% Ophthalmic Solution Addition Addition N/A DISC QL 01/01/2014 Levobunolol 0.5% Addition Addition N/A DISC QL 01/01/2014 Ophthalmic Solution Ceftibuten Suspension Generic Available for Cedax Generic N/A 1 01/01/2014 Ceftibuten Capsules Generic Available for Cedax Generic N/A 1 01/01/2014 Niacin Extended-Release Tablets Chantix Tablets Generic Available for Niaspan Changed to Step Therapy Generic N/A 1 01/01/2014 Clinical Reevaluation N/A PREV ST, QL 01/01/2014

8 8 Nicotine patch Nicotine gum Pulmozyme Inhalation Solution Changed to Quantity Limit and Age Clinical Reevaluation N/A PREV QL 01/01/2014 Clinical Reevaluation N/A PREV 01/01/2014 Clinical Reevaluation N/A 3 LA, QL 01/01/2014 Regranex Gel Deletion of Drug From Formulary Clinical Reevaluation None N/A 01/01/2014 Maxair Inhalation Aerosol Deletion of Drug From Formulary Clinical Reevaluation Ventolin HFA 1 QL 01/01/2014 Tetracycline Capsules Deletion of Drug From Formulary Clinical and Cost Doxycycline 1 01/01/2014 Reevaluation Glimepiride Tablets Change Cost Reevaluation N/A DISC 01/01/2014 Fluconazole 150 mg Change Cost Reevaluation N/A DISC QL 01/01/2014 tablets Promethazine 25 mg Change Cost Reevaluation N/A DISC 01/01/2014 tablets Promethazine 6.25 mg/5 Change Cost Reevaluation N/A DISC 01/01/2014 ml Oral Solution Gentamicin 0.3% Change Cost Reevaluation N/A DISC QL 01/01/2014 Ophthalmic Solution Polymyxin/TMP Change Cost Reevaluation N/A DISC QL 01/01/2014 Ophthalmic Solution Isosorbide Mononitrate Change Cost Reevaluation N/A DISC QL 01/01/2014 ER Tablets Prenatal Plus Tablets Change Cost Reevaluation N/A DISC QL 01/01/2014 Ventolin HFA Inhalation Aerosol Change Cost Reevaluation N/A 1 QL 01/01/2014

9 9 ProAir HFA Inhalation Aerosol Proventil HFA Inhalation Aerosol Change Cost Reevaluation Ventolin HFA 2 QL 01/01/2014 Change Cost Reevaluation Ventolin HFA 2 QL 01/01/2014 Crestor Tablets Change Clinical and Cost Reevaluation Atorvastatin 3 LA, QL 01/01/2014 Codeine Tablets Quantity Limit Restriction Added Clinical Reevaluation N/A N/A QL 01/01/2014 Hydromorphone Tablets Morphine Sulfate Extended-Release Tablets Oxycodone Tablets Venlafaxine Extended- Release Capsules/Tablets Quantity Limit Restriction Changed Quantity Limit Restriction Changed Quantity Limit Restriction Changed Clinical Reevaluation N/A N/A QL 01/01/2014 Clinical Reevaluation N/A N/A QL 01/01/2014 Clinical Reevaluation N/A N/A QL 01/01/2014 Quantity Limit Restriction Added Clinical Reevaluation N/A N/A QL 01/01/2014 Baclofen Tablets Quantity Limit Restriction Added Clinical Reevaluation N/A N/A QL 01/01/2014 Cyclobenzaprine Tablets Quantity Limit Restriction Added Clinical Reevaluation N/A N/A QL 01/01/2014 Abilify Tablets Age Restriction ; Prior Clinical Reevaluation N/A N/A QL, PA 01/01/2014 Authorization Now Required for All Ages Zostavax Injection Age Restriction Changed Clinical Reevaluation N/A N/A QL 01/01/2014 Dipyridamole Tablets Addition Addition N/A 1 10/01/2013 Eplerenone Tablets Addition Addition N/A 1 10/01/2013 Ketorolac Ophthalmic Addition Addition N/A 1 10/01/ % and 0.5% Solution Levofloxacin 0.5% Ophthalmic Solution Addition Addition N/A 1 10/01/2013

10 10 Monurol Packets Addition Addition N/A 2 QL 10/01/2013 Naphazoline Ophthalmic Addition Addition N/A 1 10/01/ % Solution Terazosin Capsules Addition Addition N/A DISC 10/01/2013 Skyla Intrauterine System Addition Addition N/A PREV 10/01/2013 Midodrine Tablets Addition Addition N/A 1 10/01/2013 Ventolin HFA Inhaler Line Extension; Addition Cost Reevaluation N/A 1 QL 10/01/2013 Escitalopram Tablets Copaxone Injection Betaseron Injection Avonex Injection Regranex Gel Mycophenolate Mofetil Tablets Sumatriptan Injection DDAVP Lomustine Capsules Changed to Step Therapy Restriction Changed to Step Therapy ; Quantity Limit Added Changed to Step Therapy ; Generic Available Generic Available for Ceenu Cost Reevaluation N/A 1 QL 10/01/2013 Clinical Reevaluation N/A 3 LA 10/01/2013 Clinical Reevaluation N/A 3 LA, ST 10/01/2013 Clinical Reevaluation N/A 3 LA, ST 10/01/2013 Clinical Reevaluation N/A 3 LA, QL 10/01/2013 Clinical Reevaluation N/A 1 QL 10/01/2013 Clinical Reevaluation N/A 1 LA, QL 10/01/2013 Clinical Reevaluation N/A 1 QL 10/01/2013 Generic N/A 1 10/01/2013

11 11 Temozolomide Capsules Acamprosate Tablets Acitretin Capsules Generic Available for Temodar Generic Available for Campral Generic Available for Soriatane Generic N/A 1 10/01/2013 Generic N/A 1 LA 10/01/2013 Generic N/A 1 LA 10/01/2013 Testim Gel Addition Addition N/A 3 LA 07/01/2013 Testosterone Cypionate Vial Addition Addition N/A 1 LA 07/01/2013 Naloxone Vial Addition Addition N/A 1 LA 07/01/2013 Balsalazide Tablets Addition Addition N/A 1 05/08/2013 Asacol 400 mg Deletion of Drug From Formulary Manufacturer Asacol HD 800 mg 2 04/19/2013 Discontinuation Glipizide/Metformin Addition Addition N/A 1 04/01/2013 Tablets First-Mouthwash BLM Addition Addition N/A 2 04/01/2013 Adapalene Cream and Gel Ondansetron 4 mg and 8 mg tablets and ODT Addition Addition N/A 1 ST 04/01/2013 Limited Access Restriction Cost Reevaluation N/A 1 04/01/2013