2018 Medicare Part D Formulary Change
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1 2018 Medicare Part D Formulary Change We may add or remove drugs from our formulary during the year. If we remove drugs from our formulary, or add prior authorizations, quantity limits and/or step therapy restrictions on a drug [or move a drug to a higher cost-sharing tier], we will let you know of the change at least 60 days before the date that the change becomes effective. However, if the Food and Drug Administration deems 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 and let you know. The product changes noted below will be implemented on the Medicare Part D Plan formulary. To see if your drug is on this list, please refer to the tables below: New Added Products: Effective 4/1/2018 Drug Cost sharing Restrictions* ALTAVERA (28) 0.15 MG-0.03 MG TABLET ALUNBRIG 180 MG TABLET ALUNBRIG 90 MG (7)-180 MG (23) TABLETS IN A DOSE CK ALUNBRIG 90 MG TABLET ATAZANAVIR 150 MG CAPSULE ATAZANAVIR 200 MG CAPSULE ATAZANAVIR 300 MG CAPSULE BYETTA 10 MCG/DOSE(250 MCG/ML)2.4 ML SUBCUTANEOUS PEN INJECTOR BYETTA 5 MCG/DOSE (250 MCG/ML)1.2 ML SUBCUTANEOUS PEN INJECTOR CARVEDILOL PHOSPHATE ER 10 MG CAPSULE,EXT.RELEASE24HR MULTIPHASE CARVEDILOL PHOSPHATE ER 20 MG CAPSULE,EXT.RELEASE24HR MULTIPHASE CARVEDILOL PHOSPHATE ER 40 MG CAPSULE,EXT.RELEASE24HR MULTIPHASE ELIQUIS 5 MG (74 TABS) TABLETS IN A DOSE CK ST ST ST 1
2 Drug Cost sharing Restrictions* ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM HERCEPTIN 150 MG INTRAVENOUS KURVELO 0.15 MG-0.03 MG TABLET LEVONORGESTREL 0.15 MG-ETHINYL ESTRADIOL 0.03 MG TABLET MAVYRET 100 MG-40 MG TABLET MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SYRINGE NAPROXEN 500 MG TABLET Tier 1 ROWEEPRA XR TABLET EXTENDED RELEASE 24 HOUR 500 MG ORAL ROWEEPRA XR TABLET EXTENDED RELEASE 24 HOUR 750 MG ORAL SELZENTRY 20 MG/ML ORAL SHINGRIX (PF) 50 MCG/0.5 ML INTRAMUSCULAR SUSPENSION TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET XIGDUO XR 2.5 MG-1,000 MG TABLET,EXTENDED RELEASE ZENPEP 40, , ,000 UNIT CAPSULE,DELAYED RELEASE Future Removed Products: Effective 4/1/2018 Drug CORMAX 0.05 % SCALP ZENPEP 20,000 UNIT-68,000 UNIT-109,000 UNIT CAPSULE,DELAYED RELEASE Reason 2
3 New Added Products: Effective 3/1/2018 Drug Cost sharing Restrictions* ADACEL (TDAP ADOLESN/ADULT)(PF)2 LF-( )-5 LF/0.5 ML IM SYRINGE ALIQO 60 MG INTRAVENOUS LA AMIODARONE 100 MG TABLET AMNESTEEM 10 MG CAPSULE AMNESTEEM 20 MG CAPSULE AMNESTEEM 40 MG CAPSULE ARIPIPRAZOLE 1 MG/ML ORAL BENLYSTA 200 MG/ML SUBCUTANEOUS AUTO- INJECTOR BENLYSTA 200 MG/ML SUBCUTANEOUS SYRINGE BOSULIF 400 MG TABLET BYDUREON BCISE 2 MG/0.85 ML SUBCUTANEOUS AUTO-INJECTOR CALQUENCE 100 MG CAPSULE LA CARVEDILOL PHOSPHATE ER 80 MG CAPSULE,EXT.RELEASE24HR MULTIPHASE CASPOFUNGIN 50 MG INTRAVENOUS CASPOFUNGIN 70 MG INTRAVENOUS DUPIXENT 300 MG/2 ML SUBCUTANEOUS SYRINGE EFAVIRENZ 50 MG CAPSULE FOSAMPRENAVIR 700 MG TABLET FOSRENOL 1,000 MG CHEWABLE TABLET GLATIRAMER 20 MG/ML SUBCUTANEOUS SYRINGE GLATIRAMER 40 MG/ML SUBCUTANEOUS SYRINGE HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR (1ML) HAVRIX (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR SYRINGE ST 3
4 HAVRIX (PF) 720 ELISA UNIT/0.5 ML INTRAMUSCULAR SUSPENSION Drug Cost sharing Restrictions* IDHIFA 100 MG TABLET LA IDHIFA 50 MG TABLET LA INGREZZA 40 MG CAPSULE LA INGREZZA 80 MG CAPSULE LA JULUCA 50 MG-25 MG TABLET KADCYLA 160 MG INTRAVENOUS KLOR-CON 20 MEQ ORAL CKET L NORGEST/E ESTRADIOL-E ESTRAD 0.15 MG-20 MCG/0.15 MG-25 MCG TABS,3MOS LARTRUVO 10 MG/ML INTRAVENOUS (19 ML) LUPRON DEPOT-PED 30 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT LYNRZA 100 MG TABLET LYNRZA 150 MG TABLET MEROPENEM 1 GRAM INTRAVENOUS MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION (10 ML) METHOTREXATE SODIUM 25 MG/ML INJECTION METHYLPHENIDATE CD 20 MG MULTIPHASE CAPSULE,EXTENDED RELEASE METHYLPHENIDATE CD 30 MG MULTIPHASE CAPSULE,EXTENDED RELEASE METHYLPHENIDATE CD 40 MG MULTIPHASE CAPSULE,EXTENDED RELEASE METHYLPHENIDATE ER 30 MG CAPSULE,EXTENDED RELEASE BIPHASIC MOXIFLOXACIN 0.5 % EYE DROPS MYLOTARG 4.5 MG (1 MG/ML INITIAL CONCENTRATION) INTRAVENOUS LA LA NERLYNX 40 MG TABLET LA 4
5 OPDIVO 100 MG/10 ML INTRAVENOUS Drug Cost sharing Restrictions* OSELTAMIVIR 6 MG/ML ORAL SUSPENSION OXALIPLATIN 100 MG INTRAVENOUS PEG GRAM-ELECTROLYTES GRAM-6.72 G-5.84 G POWDR FOR SOLN PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE POTASSIUM CHLORIDE ER 20 MEQ TABLET,EXTENDED RELEASE Tier 1 PRASUGREL 10 MG TABLET PRASUGREL 5 MG TABLET PRENATAL VITAMINS PLUS LOW IRON 27 MG IRON-1 MG TABLET PREVYMIS 240 MG TABLET PREVYMIS 240 MG/12 ML INTRAVENOUS PREVYMIS 480 MG TABLET PREVYMIS 480 MG/24 ML INTRAVENOUS RADICAVA 30 MG/100 ML INTRAVENOUS PIGGYBACK RISEDRONATE 35 MG TABLET RITUXAN 10 MG/ML CONCENTRATE,INTRAVENOUS (10 ML) SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER CKET SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER CKET SEVELAMER CARBONATE 800 MG TABLET TRAMADOL ER 100 MG TABLET,EXTENDED RELEASE 24HR MPHASE TRAMADOL ER 200 MG TABLET,EXTENDED RELEASE 24HR MPHASE 5
6 Drug Cost sharing Restrictions* TRAMADOL ER 300 MG TABLET,EXTENDED RELEASE 24HR MPHASE (MATRIX DELIVERY) TREANDA 25 MG INTRAVENOUS POWDER FOR TRISENOX 2 MG/ML INTRAVENOUS TWINRIX (PF) 720 ELISA UNIT-20 MCG/ML INTRAMUSCULAR SYRINGE TYMLOS 80 MCG/DOSE (3,120 MCG/1.56 ML) SUBCUTANEOUS PEN INJECTOR VAQTA (PF) 25 UNIT/0.5 ML INTRAMUSCULAR SUSPENSION VAQTA (PF) 50 UNIT/ML INTRAMUSCULAR SUSPENSION VERZENIO 100 MG TABLET LA VERZENIO 150 MG TABLET LA VERZENIO 200 MG TABLET LA VERZENIO 50 MG TABLET LA VIGABATRIN 500 MG ORAL POWDER CKET LA XARELTO 10 MG TABLET XARELTO 15 MG (42)-20 MG (9) TABLETS IN A DOSE CK XARELTO 15 MG TABLET XARELTO 20 MG TABLET XATMEP 2.5 MG/ML ORAL ZENPEP 20,000-63,000-84,000 UNIT CAPSULE,DELAYED RELEASE Future Removed Products: Effective 3/1/2018 Drug ACETASOL HC 1 %-2 % EAR DROPS AMINOSYN II 7 % INTRAVENOUS AMPICILLIN 125 MG/5 ML ORAL SUSPENSION AMPICILLIN 250 MG CAPSULE Reason 6
7 Drug AMPICILLIN 250 MG/5 ML ORAL SUSPENSION BROMFENAC 0.09 % EYE DROPS BUDESONIDE 32 MCG/ACTUATION NASAL SPRAY ELIPHOS 667 MG TABLET ENGERIX-B PEDIATRIC (PF) 10 MCG/0.5 ML INTRAMUSCULAR SUSPENSION MENOMUNE - A/C/Y/W-135 (PF) 50 MCG SUBCUTANEOUS NECON 1/50 (28) 1 MG-50 MCG TABLET NECON 10/11 (28) 0.5 MG-35 MCG(10)/1 MG-35 MCG(11) TABLET SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SYRINGE TWINRIX (PF) 720 ELISA UNIT-20 MCG/ML INTRAMUSCULAR SUSPENSION ZAMICET 10 MG-325 MG/15 ML ORAL ZENCHENT FE 0.4 MG-35 MCG (21)/75 MG (7) CHEWABLE TABLET Reason 7
8 For more information about how these changes may affect your cost-sharing, such as copayments or coinsurance, or for more information about asking for an updated coverage determination or a formulary exception, please see the plan Evidence of Coverage. Alternative drugs are drugs in the same therapeutic category/class as the affected drug. Only your doctor can determine alternative drugs that are appropriate for you given the individualized nature of drug therapy. Please talk to your doctor about any changes or recommendations to your medical care and prescription drug therapy. Alternative drugs and additional information about formulary changes can be found on the plan formulary, *Indicates a restriction of Step Therapy, Prior Authorization or Quantity Level Limits may exit LA = Limited Access, = Prior Authorization, = Quantity Limit, ST = Step Therapy Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayment/coinsurance may change on January 1, 2019 This document includes GuildNet Gold and GuildNet Health Advantage partial formulary as of 04/01/2018. For a complete, updated formulary, please visit our Web site at or call the Member Service number below. This information is available for free in other languages. Please contact Member Services number at for additional information. (TTY users should call ). Hours are Monday through Friday, 8am -8pm. Member Services has free language interpreter services available for non-english speakers. Esta información esta disponible en otros idiomas a gratis. Por favor llame a Servicios a los Clientes, al por información adicional. (Los usuarios de TTY deben llamar al ). Se atiende de lunes a viernes, de 8 a. m. a 8 p. m. Servicios a los Clientes tienen los servicios gratuitos de intérprete de idioma disponibles para altavoces de no-inglés. GuildNet Gold and GuildNet Health Advantage are HMO-POS SNP plans with Medicare and New York State contracts. Enrollment in GuildNet Gold and GuildNet Health Advantage depends on contract renewal. 8
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Y0133_StepTherapyCriteria _C 10/18/18 Y0133_StepTherapyCriteria _C es 10/18/18
Step Therapy Grid Certain cost-effective drugs must be used before other more expensive drugs are covered. For example, certain brand-name medications will only be covered if a generic alternative has
HAP/Midwest Health Advantage MI Health Link (MMP) Updates
January, 2018 01/01/2018 hydrocortisone butyrate hydrocortisone butyrate 01/01/2018 MIRVASO brimonidine tartrate 01/01/2018 AZACTAM aztreonam 01/01/2018 AZACTAM aztreonam 01/01/2018 mesalamine mesalamine
Advantage by Peach State Health Plan 2012 Prior Authorization Listing. Approved 10/23/2011 Effective October 2011
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Step Therapy Requirements. Effective: 11/01/2018
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2011 Formulary Addendum
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ANTIDEPRESSANTS. Details. dose pack Viibryd 10 mg tablet Viibryd 20 mg tablet Viibryd 40 mg tablet. Criteria
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PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES Select Formulary April 1, 2018 Updates. Formulary Alternatives
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ALPHA BLOCKERS. Products Affected Step 1: Details. Step 2: Rapaflo 4 mg capsule Rapaflo 8 mg capsule
CHRISTUS Health Plan Generations (HMO) CHRISTUS Health Plan Generations Plus (HMO) 2018 Premier Performance Standard Step Therapy PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS
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Network Health Insurance Corporation Upcoming Negative Changes to the Medicare Part D Formulary
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Health Partners Medicare Prime 2019 Formulary Changes
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