Network Health Insurance Corporation Upcoming Negative Changes to the Medicare Part D Formulary
|
|
|
- Suzan Nicholson
- 5 years ago
- Views:
Transcription
1 Requesting an Exception to the Formulary You can ask Network Health Insurance Corporation to make an exception to our coverage rules. Generally, we will only approve your request for an exception if alternative formulary drugs would not be as effective in treating your condition and would have a negative effect on your health. Contact us to ask for an initial coverage decision for a formulary, tier or utilization restriction (specific criteria) exception. When you re requesting an exception, please submit a statement from your physician supporting your request. For more detailed information about your Network Health Insurance Corporation prescription drug coverage, please review your Evidence of Coverage and other plan materials. The following brand name drugs will have a tier increase, with an increase in the member s share of the cost. For each drug, a generic alternative is now available. Drug Name Effective Date New Tier Alternative Drug Alternative Drug Tier Exelon 4.6 mg/24 hour patch July 1, Rivastigmine 4.6 mg/24hr patch Tier 2: Exelon 9.5 mg/24 hour patch July 1, Rivastigmine 9.5 mg/24hr patch Tier 2: Exelon 13.3 mg/24 hour patch July 1, Rivastigmine 13.3 mg/24hr patch Tier 2: Namenda 2 mg/ml solution July 1, Memantine 2 mg/ml solution Tier 2: Lincocin 300 mg/ml vial August 1, Lincomycin 600 mg/2 ml vial Tier 2: Tegretol XR 100mg October 1, Carbamazepine ER 100mg Tier 2: Voltaren 1% gel October 1, Diclofenac 1% gel Tier 2: Abilify Discmelt 10 mg March 1, 2016 Aripiprazole odt 10 mg Tier 2: Cedax 90 mg/5 ml suspension March 1, 2016 Cedax 180 mg/5 ml suspension Tier 4: Non- Cefditoren pivoxil 200 mg tab March 1, 2016 Consult with provider N/A Cortisporin ear solution March 1, 2016 Neomycin-polymyxin-HC ear suspension Tier 2: Demadex 100 mg March 1, 2016 Torsemide 100 mg Tier 2: Dilaudid-HP 10 mg/ml vial March 1, 2016 Hydromorphone HCl 10 mg/ml vial Tier 2: Eloxatin 100 mg/20 ml vial March 1, 2016 Oxaliplatin 100 mg/20 ml vial Tier 5: Specialty Enjuvia mg March 1, 2016 Premarin mg Tier 3: Updated 6/2016 1
2 Foscarnet 24 mg/ml infusion bottle March 1, 2016 Consult with provider N/A IPOL single dose syringe March 1, 2016 IPOL vial Tier 3: Lescol 20 mg capsule March 1, 2016 Fluvastatin sodium 20 mg cap Tier 2: Lescol 40 mg capsule March 1, 2016 Fluvastatin sodium 40 mg cap Tier 2: Levaquin 25 mg/ml solution March 1, 2016 Levofloxacin 500 mg/20 mg vial Tier 2: Liptruzet mg March 1, 2016 Zetia 10 mg ; Atorvastatin 10 mg Tier 3: ; Tier 2: Liptruzet mg March 1, 2016 Zetia 10 mg ; Atorvastatin 20 mg Tier 3: ; Tier 2: Liptruzet mg March 1, 2016 Zetia 10 mg ; Atorvastatin 40 mg Tier 3: ; Tier 2: Liptruzet mg March 1, 2016 Zetia 10 mg ; Atorvastatin 80 mg Tier 3: ; Tier 2: Lotrel 5-40 mg capsule March 1, 2016 Amlodipine-benazepril 5-40 mg Tier 2: Naftin 1% cream March 1, 2016 Naftifine HCl 1% cream Tier 4: Non- Naprosyn 250 mg March 1, 2016 Naproxen 250 mg Tier 2: Neumega 5 mg vial March 1, 2016 Consult with provider N/A Spectracef 400 mg dose pack tab March 1, 2016 Consult with provider N/A Suclear bowel prep kit March 1, 2016 Suprep bowel prep kit Tier 4: Non- Teveten 600 mg March 1, 2016 Eprosartan mesylate 600 mg tab Tier 2: Teveten HCT mg tab March 1, 2016 Eprosartan mesylate 600 mg tab; Tier 2: ; Tier 2: Hydrochlorothiazide 12.5 mg tab Teveten HCT mg tab March 1, 2016 Eprosartan mesylate 600 mg tab; Tier 2: ; Tier 2: Hydrochlorothiazide 25 mg tab Ticlopidine 250 mg March 1, 2016 Consult with provider N/A Viibryd titration pack March 1, 2016 Viibryd mg starter pack Tier 3: Voltaren-XR 100 mg March 1, 2016 Diclofenac sod ER 100 mg tab Tier 2: Apexicon 0.05% ointment April 1, 2016 Diflorasone 0.05% ointment Tier 2: Auvi-Q 0.15 mg auto-injector April 1, 2016 Epipen JR 2-pak 0.15 mg injctr Tier 3: Auvi-Q 0.3 mg auto-injector April 1, 2016 Epipen 2-pak 0.3 mg auto-injct Tier 3: Updated 6/2016 2
3 Avandia 8 mg April 1, 2016 Avandia 4 mg Tier 4: Non- Demadex 20 mg April 1, 2016 Torsemide 20 mg Tier 2: Endodan mg April 1, 2016 Oxycodone-aspirin mg Tier 2: Factive 320 mg April 1, 2016 Consult with provider N/A Flagyl ER 750 mg April 1, 2016 Metronidazole 500 mg Tier 2: Lomustine 10 mg capsule April 1, 2016 Gleostine 10 mg capsule Tier 4: Non- Lomustine 100 mg capsule April 1, 2016 Gleostine 100 mg capsule Tier 4: Non- Lomustine 40 mg capsule April 1, 2016 Gleostine 40 mg capsule Tier 4: Non- Naprosyn 375 mg April 1, 2016 Naproxen 375 mg Tier 2: Ortho-cept 28 day April 1, 2016 Apri 28 day Tier 2: Percodan mg April 1, 2016 Oxycodone-aspirin mg Tier 2: Pletal 100 mg April 1, 2016 Cilostazol 100 mg Tier 2: Pletal 50 mg April 1, 2016 Cilostazol 50 mg Tier 2: Prandimet 1 mg-500 mg April 1, 2016 Repaglinide-metformin mg Tier 2: Prandimet 2 mg-500 mg April 1, 2016 Repaglinide-metformin mg Tier 2: Roxicet mg oral solution April 1, 2016 Oxycodone HCl 5 mg/5 ml soln Tier 2: Sprix mg nasal spray April 1, 2016 Consult with provider N/A Tobramycin 80 mg/100 ml NS April 1, 2016 Tobramycin 10 mg/ml vial Tier 2: Triamcinolone 55 mcg nasal spray April 1, 2016 Fluticasone Prop 50 mcg spray Tier 2: Ultressa DR 13,800 unit capsule April 1, 2016 Zenpep DR capsule Tier 4: Non- Ultressa DR 20,700 unit capsule April 1, 2016 Zenpep DR capsule Tier 4: Non- Ultressa DR 23,000 unit capsule April 1, 2016 Zenpep DR capsule Tier 4: Non- Xylocaine 4% solution April 1, 2016 Lidocaine HCl 4% solution Tier 2: Anaprox 275mg May 1, 2016 Naproxen sodium 275mg Tier 2: Androgel 1% gel pump May 1, 2016 Androgel 1% gel packet Tier 3: Arzerra 100mg/5ml vial May 1, 2016 Consult with provider N/A Lopressor 5mg/5ml ampule May 1, 2016 Metoprolol tartrate 1mg/ml amp Tier 2: Norpramin 75mg May 1, 2016 Desipramine 75mg Tier 2: Prilosec DR 10mg capsule May 1, 2016 Omeprazole DR 10mg capsule Tier 1: Preferred Updated 6/2016 3
4 Prilosec DR 20mg capsule May 1, 2016 Omeprazole DR 20mg capsule Tier 1: Preferred Prilosec DR 40mg capsule May 1, 2016 Omeprazole DR 40mg capsule Tier 1: Preferred Reprexain mg May 1, 2016 Hydrocodone-ibuprofen 5-200mg Tier 2: Advicor 1,000-20mg June 1, 2016 Niacin ER ; Altoprev 20mg Tier 2: ; Tier 4: Non- Advicor 1,000-40mg June 1, 2016 Niacin ER ; Altoprev 40mg Tier 2: ; Tier 4: Non- Advicor mg June 1, 2016 Niacin ER 500mg; Altoprev 20mg Tier 2: ; Tier 4: Non- Advicor mg June 1, 2016 Niacin ER 750mg; Altoprev 20mg Tier 2: ; Tier 4: Non- Alsuma 6mg/0.5ml auto-inject June 1, 2016 Sumatriptan 6mg/0.5ml injection Tier 2: Amnesteem 10mg capsule June 1, 2016 Claravis 10mg capsule Tier 2: Amnesteem 20mg capsule June 1, 2016 Claravis 20mg capsule Tier 2: Amnesteem 40mg capsule June 1, 2016 Claravis 40mg capsule Tier 2: Avandamet 2mg- June 1, 2016 Metformin ; Avandia 2mg Tier 1: Preferred ; Tier 4: Non- Coly-mycin S ear drops June 1, 2016 Cortisporin-TC ear suspension Tier 4: Non- Comvax vaccine vial June 1, 2016 Consult with provider N/A Dilaudid 2mg/ml ampule June 1, 2016 Dilaudid 4mg/ml ampule Tier 4: Non- Fulyzaq 125 mg DR June 1, 2016 Consult with provider N/A Simcor 1,000-20mg June 1, 2016 Simvastatin 20mg ; Niacin ER Simcor 1,000-40mg June 1, 2016 Simvastatin 40mg ; Niacin ER Simcor mg June 1, 2016 Simvastatin 20mg ; Niacin ER 500mg Simcor mg June 1, 2016 Simvastatin 40mg ; Niacin ER Tier 1: Preferred ; Tier 2: Tier 1: Preferred ; Tier 2: Tier 1: Preferred ; Tier 2: Tier 1: Preferred ; Tier 2: Updated 6/2016 4
5 Simcor mg June 1, 2016 Simvastatin 20mg ; Niacin ER 750mg Tier 1: Preferred ; Tier 2: Tofranil-PM 100mg capsule June 1, 2016 Imipramine pamoate 100 mg capsule Tier 2: Tofranil-PM 125mg capsule June 1, 2016 Imipramine pamoate 125 mg capsule Tier 2: Tofranil-PM 150mg capsule June 1, 2016 Imipramine pamoate 150 mg capsule Tier 2: Tofranil-PM 75mg capsule June 1, 2016 Imipramine pamoate 75 mg capsule Tier 2: Treanda 45mg/0.5ml vial June 1, 2016 Treanda 100 mg/vial Tier 5: Specialty Wellbutrin 75mg June 1, 2016 Buproprion HCl 75mg Tier 2: Zolpimist 5mg oral spray June 1, 2016 Zolpidem 5mg ; Edluar 5mg SL Tier 2: ; Tier 4: Non- Cantil 25 mg July 1, 2016 Consult with provider N/A Daunoxome 50 mg (2mg/ml) vial July 1, 2016 Consult with provider N/A Flo-pred 16.7(15) mg/5 ml susp July 1, 2016 Prednisolone 15 mg/5 ml solution Tier 2: Garamycin 0.3% eye drops July 1, 2016 Gentamicin 0.3% eye drops Tier 2: Gelnique 3% gel July 1, 2016 Gelnique 10% gel sachets Tier 4: Non- Keflex 250 mg capsule July 1, 2016 Cephalexin 250 mg capsule Tier 2: Keflex 500 mg capsule July 1, 2016 Cephalexin 500 mg capsule Tier 2: Keflex 750 mg capsule July 1, 2016 Cephalexin 750 mg capsule Tier 2: Lotrel mg capsule July 1, 2016 Amlodipine-benazepril mg Tier 2: Otezla starter pack July 1, 2016 Otezla 28 day starter pack Tier 5: Specialty Primsol 50 mg/5 ml oral solution July 1, 2016 Trimethoprim 100mg Tier 2: Promacta 75 mg July 1, 2016 Promacta 25 mg ; 50 mg Tier 5: Specialty Uceris 2 mg rectal foam July 1, 2016 Consult with provider N/A Zazole vaginal 0.4% cream July 1, 2016 Zazole vaginal 0.8% cream Tier 4: Non- Updated 6/2016 5
Medicare Part D 2016 Formulary Changes Service To Senior and OC Preferred
Medicare Part D 2016 Formulary s Service To Senior and OC Preferred 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
Quarterly pharmacy formulary change notice
The formulary changes listed in the table below apply to all Anthem HealthKeepers Plus and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) members. These formulary changes,
Amitriptyline Hydrochloride Heart Health & BP Amlodipine Besylate 5mg Norvasc Antibiotics Amoxicillin 500 mg Amoxil
School Corp Formulary Antiviral Acyclovir 400mg Zovirax Asthma Advair Diskus Diskus 250/50 Fluticasone/Salmeterol Asthma Albuterol Sulfate 2.5 mg/3 ml Proventil Arthritis and Pain Allendronate Sodium 70
Medicare Part D 2016 Formulary Changes Desert Preferred Choice
Medicare Part D 2016 Formulary s Desert Preferred Choice 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,
2017 Formulary Changes Year to Date
2017 Formulary Changes Year to Date Health Choice Arizona may add or remove drugs from our formulary during the year. If we remove drugs from our formulary, add prior authorization, quantity limits and/or
Amitriptyline Hydrochloride Heart Health & BP Amlodipine Besylate 5mg Norvasc Antibiotics Amoxicillin 500 mg Amoxil
Antiviral Acyclovir 400mg Zovirax Asthma Advair Diskus Diskus 250/50 Fluticasone/Salmeterol Asthma Albuterol Sulfate 2.5 mg/3 ml Proventil Arthritis and Pain Allendronate Sodium 70 mg Fosamax Arthritis
Quarterly pharmacy formulary change notice
Quarterly pharmacy formulary change notice Provider update Summary: The formulary changes listed in the table below were reviewed and approved at our second quarter 2018, Pharmacy and Therapeutics Committee
Quarterly pharmacy formulary change notice
MEDICAID PROVIDER BULLETIN October 2018 The formulary changes listed in the table below were reviewed and approved at the second-quarter 2018 Pharmacy and Therapeutics Committee meeting. Effective October
AETNA BETTER HEALTH January 2017 Formulary Change(s)
AETNA BETTER HEALTH January 2017 Formulary Change(s) The following updates will be made to the Aetna Better Health of MI formulary on March 1, 2017 Drug Name, Strength, Dosage Form ALFUZOSIN HCL ER 10
Riesbeck's Pharmacy Reward Club Generic Medication List February 2018 $4 30 Day Supply
Allergy, Cold & Flu Antibiotic Treatments Arthritis & Pain Benzonatate 100mg cap 14 42 Diphenhydramine HCl Cap 50 MG 30 90 Diphenhydramine HCl Inj 50MG/ML 1 3 Diphenhydramine HCl Liquid 12.5 MG/5ML 720ml
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
Quarterly pharmacy formulary change notice
Provider Bulletin October 2018 Quarterly pharmacy formulary change notice The formulary changes listed in the table below apply to all Anthem HealthKeepers Plus patients. The changes listed in the table
Riesbeck's Pharmacy Reward Club Generic Medication List October 2017
Allergy, Cold & Flu Antibiotic Treatments Arthritis & Pain Benzonatate 100mg cap 14 42 Diphenhydramine HCl Cap 50 MG 30 90 Diphenhydramine HCl Inj 50MG/ML 1 3 Diphenhydramine HCl Liquid 12.5 MG/5ML 720ml
Riesbeck's Pharmacy Reward Club Generic Medication List September 2017
Drug Category Allergy, Cold & Flu Antibiotic Treatments Arthritis & Pain Riesbeck's Benzonatate 100mg cap 14 42 Diphenhydramine HCl Cap 50 MG 30 90 Diphenhydramine HCl Liquid 12.5 MG/5ML 720ml 2160ml Hydroxyzine
Formulary Change Notice
Formulary Change Notice HealthPartners may remove drugs from our formulary (list of covered drugs) or add rules about whether and when certain drugs are covered during the year. The chart below contains
ALLERGIC CONJUNCTIVITIS AGENTS
2018 5 Tier Standard- Keystone First VIP Choice Document: 2018 Step Therapy Formulary ID: 18390 Last Updated: 04/2018 Effective Date: 05-01-2018 ALLERGIC CONJUNCTIVITIS AGENTS epinastine 0.05 % eye drops
Aetna Better Health Illinois Premier Plan. November 2015 Formulary Updates. October 2015 Formulary Updates
Aetna Better Health Illinois Premier Plan November 2015 Formulary Updates desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg RIVASTIGMINE DIS 13.3/24; QL (30 patches/30 days) RIVASTIGMINE DIS 4.6MG/24;
Medicare Part D 2016 Formulary Changes Service To Senior and OC Preferred
Medicare Part D 2016 Formulary s Service To Senior and OC Preferred 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
LABEL NAME CHANGE EFFECTIVE DATE ARCALYST 220 MG INJECTION
LABEL NAME CHANGE EFFECTIVE DATE ARCALYST 220 MG INJECTION Added Prior Authorization 7/1/17 CORLANOR 5 MG TABLET Added Prior Authorization 7/1/17 CORLANOR 7.5 MG TABLET Added Prior Authorization 7/1/17
Aetna Better Health of Illinois Medicaid Formulary Updates
October 2017 o DOXYLAMINE SUCCINATE 25mg-QL o DULOXETINE CAP 40MG DR-QL o GUANFACIN ER TABS (all strengths)-ql o TOBRAMYCIN NEBU SOLUTION- PA August 2017 Aetna Better Health of Illinois Medicaid 2017 Formulary
High-Cost Drug Exclusions
PHARMACY SERVICES High-Cost Exclusions The high cost medications listed below are excluded from coverage because lower cost similar alternatives are available. To help you get the best health benefit at
ARBS MEDICATION(S) SUBJECT TO STEP THERAPY DIOVAN HCT MG TAB, DIOVAN HCT MG TABLET
ARBS DIOVAN HCT 160-12.5 MG TAB, DIOVAN HCT 80-12.5 MG TABLET 30-day trial of a Step 1 drug in the previous 120 days is required. Step 1 Drugs: Losartan, Losartan/HCTZ PAGE 1 LAST UPDATED 05/2016 BILE
All Pharmacy and Prescribing Providers. Subject: State Maximum Allowable Cost (MAC) Updates
INDIANA HEALTH COVERAGE PROGRAMS P R O V I D E R B U L L E T I N B T 2 0 0 7 1 2 M A Y 2 9, 2 0 0 7 To: All Pharmacy and Prescribing Providers Subject: State Maximum Allowable Cost (MAC) Updates Effective
PRIOR ADAP FORMULARY - RX OPTIONS
PRIOR ADAP FORMULARY - RX OPTIONS Created by Care Directions Case Manageent - 602-264-2273 MEDICATION Pharacies ALLERGY/COUGH/COLD DIPHENHYDRAMINE 50 MG FLUTICASONE $35 HYDROXYZINE 25 MG, 50 MG X LORATIDINE
Table 1: Price increases for Brand Name Drugs with Generic Equivalents
Table 1: Price increases for Brand Name Drugs with Generic Equivalents Brand Name Medication and Dose Total % Change Since 10/2012 ACTOS 15 MG TABLET 6.36 11.03 73.39% ACTOS 30 MG TABLET 9.7 16.80 73.23%
AETNA BETTER HEALTH January 2017 Formulary Change(s)
AETNA BETTER HEALTH January 2017 Formulary Change(s) The following updates will be made to the Aetna Better Health of MI formulary on February 1, 2017 Drug Name, Strength, Dosage Form IVERMECTIN 3 MG TABLET
Capital BlueCross Open/Closed Formulary Update (1 st Quarter 2017)
Capital BlueCross Open/Closed Formulary Update (1 st Quarter 2017) The Capital BlueCross formulary is a reference list of prescription drugs that contains a wide range of generic and brand drugs that have
TennCare Program TN MAC Price Change List As of: 03/30/2017
1 TN List Run : 03/30/17 Old PRAZOSIN HCL 5 MG CAPSULE ORAL 03/29/2017 1.11209 1.12560 ( 1.2) CAPTOPRIL 12.5 MG TABLET ORAL 07/07/2015 1.07191 1.10416 ( 2.9) ISOSORBIDE DINITRATE 5 MG TABLET ORAL 03/29/2017
2017 Step Therapy Criteria
FRESENIUS TOTAL HEALTH 2017 Step Therapy Updated 07/01/2017. For more recent information or other questions, please contact Fresenius Total Health Customer Service at 1-855-598-6774 / TTY 1-844-209-9094.
VIVA Health, Inc. Part D Cumulative Formulary Changes for 2009
ulary ulary Effective ADDS 00472088282 ACETASOL HC 2%; 1% SOLN Pref(1) no 1/29/2009 3/1/2009 68382026101 ACETAZOLAMIDE 500MG CP12 Pref(1) yes 3/24/2009 5/1/2009 00078056651 AFINITOR 5MG TABS Pref (4);
2016 Medicare Part D Formulary Change
2016 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
Health Partners Medicare Prime 2019 Formulary Changes
Health Partners Medicare Prime 2019 Formulary Changes Changes occur, for example, because new drugs come on the market, a drug is moved to a different cost-sharing level (tier), or a generic version becomes
Alprazolam 0.25mg, 0.5mg, 1mg tablets
Presbyterian Senior Care (HMO) / Presbyterian MediCare PPO Quantity Limits Effective November 1, 2014 For the most recent list of drugs or other questions, please contact the Presbyterian Customer Service
Special Generic Drug Pricing Program
FREE PICK-UP & DELIVERY Flu-Shots Specialty prescription Compounding Wellness center providing health screenings for hypertension and diabetes $3 Special Generic Prescription Drug Program only offered
Your prescription benefit updates Formulary Updates - Effective January 1, 2019
Your prescription benefit updates Formulary Updates - Effective January 1, 2019 Medications are grouped by the conditions they treat. Each medication is placed in a tier that shows the amount you will
Partners Notice of Change March 2017
New Added Products: Effective 3/1/2017 Drug Reason Tier Restrictions abacavir 600 mg-lamivudine 300 QL ADRENACLICK 0.15 MG/0.15 ML INJECTION,AUTO- INJECTOR ADRENACLICK 0.3 MG/0.3 ML INJECTION, AUTO- INJECTOR
2016 PRESCRIPTION DRUG LIST UPDATES
2016 PRESCRIPTION DRUG LIST UPDATES Evergreen Health 1 st Quarter Below are key updates to the four-tier EHB Prescription Formulary, effective January 1, 2016. Please consult the full formulary for more
CRITERIA Trial of two generic formulary products from the following: atomoxetine or ADHD stimulant medication.
ADHD STIMULANTS ATOMOXETINE HCL, DEXEDRINE 10 MG TABLET, DEXEDRINE 5 MG TABLET, DEXMETHYLPHENIDATE HCL, DEXMETHYLPHENIDATE HCL ER, DEXTROAMPHETAMINE 10 MG TAB, DEXTROAMPHETAMINE 5 MG TAB, DEXTROAMPHETAMINE
Plan Year CCHP Senior Program (HMO) Step Therapy Criteria (ST)
Plan Year 2016 CCHP Senior Program (HMO) Step Therapy Criteria (ST) Step Therapy: In some cases, CCHP Senior Program (HMO) requires you to first try certain drugs to treat your medical condition before
Professionalism & Service with Great Prices
Acyclovir Capsules 200mg Viruses 30 90 Albuterol Syrup 2mg/5ml Asthma 120 360 Albuterol Sulfate Solution 0.05% * Asthma ----- ----- 20 60 Albuterol Sulfate Solution 0.083% Asthma ----- ----- 75 225 Alendronate
PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES Select Formulary April 1, 2018 Updates. Formulary Alternatives
PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES Select April 1, 2018 Updates Drug Name adapalene-benzoyl-peroxide Gel 0.1-2.5% (Brand = Epiduo ) prasugrel hcl (Brand = Effient ) vigabatrin pak 500 mg (Brand
Aetna Better Health of Michigan 1333 Gratiot Avenue, Suite 400 Detroit, MI AETNA BETTER HEALTH January 2017 Formulary Change(s)
AETNA BETTER HEALTH January 2017 Formulary Change(s) The following updates will be made to the Aetna Better Health of MI formulary on July 1, 2017 ADAPALENE 0.1% CREAM ADAPALENE 0.1% GEL ATORVASTATIN 10
PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES Select Formulary October 1, 2018 Updates. Formulary. Alternatives
PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES Select October 1, 2018 Updates Drug Name efavirenz 600mg (Brand = Sustiva ) trientine (Brand = Syprine ) hydrocortisone lot 0.1% (Brand = Locoid ) sumatriptan-naproxen
Neighborhood Medicaid Formulary Changes: June 2017
Neighborhood Medicaid Formulary Changes: June 2017 The following changes to the Neighborhood Medicaid Formulary were recently approved by the Pharmacy and Therapeutics (P&T) Committee. All changes were
PRESCRIPTION SAVINGS CLUB FLAT- PRICED GENERIC DRUG LIST (EMDEON) Effective August 20, 2014
PRESCRIPTION SAVINGS CLUB FLAT- PRICED GENERIC DRUG LIST (EMDEON) Effective August 20, 2014 The Prescription Savings Club provides its members with significant savings on prescription medications. The
PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES Select Formulary April 1, 2018 Updates. Formulary Alternatives
PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES Select April 1, 2018 Updates Drug Name adapalene-benzoyl-peroxide Gel 0.1-2.5% (Brand = Epiduo ) prasugrel hcl (Brand = Effient ) vigabatrin pak 500 mg (Brand
ANGIOTENSIN RECEPTOR BLOCKERS STEP THERAPY
South Country Health Alliance 2017 Step Therapy Formulary ID: 17431 Last Updated: 10/20/2017 Effective Date: 11-01-2017 ANGIOTENSIN RECEPTOR BLOCKERS STEP THERAPY BENICAR 20 MG BENICAR 40 MG BENICAR 5
TN Cover Rx Tennessee CoverRx MAC Price Change List As of: 04/26/2018
1 Tennessee CoverRx List Run : 04/26/18 Dosage Form amiodarone HCl 200 MG TABLET ORAL 04/25/2018 0.16102 0.14405 11.8 hydralazine HCl 100 MG TABLET ORAL 04/25/2015 0.11390 0.10854 4.9 hydralazine HCl 25
ACYCLOVIR OINT (CCHP2017)
ACYCLOVIR OINT (CCHP2017) acyclovir 5 % topical ointment Step Therapy requires trial of one (1) of the following: oral generic acyclovir, oral generic famciclovir, oral generic valacyclovir. 1 ALPHAGAN
U T I L I Z A T I O N E D I T S
I N D I A N A H E A L T H C O V E R A G E P R O G R A M S U T I L I Z A T I O N E D I T S A P R I L 1 9, 2 0 1 2 s for s Refer to Provider Bulletin BT200709 for additional information regarding the Mental
2018 CareOregon Advantage Part D Formulary Changes
2018 CareOregon Advantage Part D Formulary Changes Abbreviations: AGE = Age Restriction; PA = Prior Authorization Required; QL = Quantity Limit; ST = Step Therapy Required; LD = Limited Distribution; BvD
Hundreds of Choices. More Savings Every Day. 8 and $ 12 Generics Also Available. Based on 30-day supply at commonly prescribed doses
4$ Hundreds of Choices. More Savings Every Day. $ 8 and $ 12 Generics Also Available. Based on 30-day supply at commonly prescribed doses EFF. DATE 09/2017 List subject to change ALLERGIES, COLD AND FLU
ACYCLOVIR OINT (CCHP2017)
ACYCLOVIR OINT (CCHP2017) acyclovir 5 % topical ointment Step Therapy requires trial of one (1) of the following: oral generic acyclovir, oral generic famciclovir, oral generic valacyclovir. 1 ALPHAGAN
These programs and quantity limitations may not apply. Check your certificate or other plan information for benefit details.
FlexRx Standard Utilization Management (PA, QL,) Updates January 1, 2018 How to use this drug list This drug list includes updates to Utilization Management (UM) programs. UM may include a prior authorization
ALOGLIPTIN STEP. Step Therapy Requirements Effective April 1, 2018
Step Therapy Requirements Effective April 1, 2018 ALOGLIPTIN STEP alogliptin 12.5 mg tablet alogliptin 12.5 mg-metformin 1,000 mg tablet alogliptin 12.5 mg-metformin 500 mg tablet alogliptin 12.5 mg-pioglitazone
ALOGLIPTIN STEP. Step Therapy Requirements Effective June 1, 2018
Step Therapy Requirements Effective June 1, 2018 ALOGLIPTIN STEP alogliptin 12.5 mg tablet alogliptin 12.5 mg-metformin 1,000 mg tablet alogliptin 12.5 mg-metformin 500 mg tablet alogliptin 12.5 mg-pioglitazone
2018 Formulary Notice of Change Prescription Drug Plans
2018 Formulary Notice of Change Prescription Drug Plans WellCare Prescription Insurance, Inc. Plans in all states: WellCare Classic (PDP) WellCare may add or remove drugs from our formulary during the
Removed from formulary. Removed from formulary. Added to formulary. Quanitity limit changed. Removed from formulary. Removed from formulary
AETNA BETTER HEALTH October 2017 Formulary Change(s) The following updates will be made to the Aetna Better Health of MI formulary on October 1, 2017 MIDAZOLAM HCL 5MG/ML VIAL MIDAZOLAM HCL 10 MG/2 ML
Beneficiary Advisory Panel Handout Uniform Formulary Decisions 24 June 2010
Beneficiary Advisory Panel Handout Uniform Formulary Decisions 24 June 2010 PURPOSE: The purpose of this handout is to provide BAP Committee members with a reference document for the relative clinical
Blue Cross and Blue Shield of Minnesota GenRx Formulary Updates
Blue Cross and Blue Shield of Minnesota GenRx Formulary Updates July 2018 TRADE NAME (generic name) or generic name ADVAIR DISKUS (fluticasone-salmeterol aer powder ba 100-50 mcg/dose) Brand Addition ADVAIR
2016 FORMULARY ADDENDUM NOTICE OF CHANGE
2016 FORMULARY ADDENDUM NOTICE OF CHANGE (PRESCRIPTION DRUG PLANS) WELLCARE PRESCRIPTION INSURANCE, INC. WellCare Simple (PDP) WellCare Classic (PDP) WellCare Extra (PDP) This is a listing of the changes
Fruth Pharmacy Prescription Savings Club Prescription Club October 2010 Generics item list 30 Day Qty
Fruth Pharmacy Prescription Savings Club Prescription Club October 2010 Generics item list Antihistamine Drugs Cyproheptadine HCl Tab 4 mg Anti-Infective Agents Diphenhydramine HCl Cap mg Promethazine
RETAIL PRESCRIPTION PROGRAM DRUG LIST -- WALMART Revised 8/24/11
Allergies & Cold and Flu $4, 30-day $10, 90-day Benzonatate 100mg cap 14 42 Loratadine 10mg tab 30 90 Promethazine DM syrup 120ml 360ml Antibiotic Treatments Amoxicillin 125mg/5ml susp (80ml bottle) 1
Pharmacy Savings Program
Pharmacy Savings Program SELECT GENERICS DRUG LIST The Pharmacy Savings Program provides you with savings on select generic medications included on this list. The prices for these select generic medications
3 Tier Formulary Additions
3 Tier Formulary Additions Drug Name Tier Category Management ACCU-CHECK GUIDE ME GLUCOSE METER 3 Diabetic Supplies Step Therapy applies pyridostigmine bromide 60mg/5ml syrup 1 Antimyasthenic Agents New
Medicare Part D 2012 Formulary Changes Service To Senior and Total Fit
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,
AMANTADINE 50 MG/5 ML SYRUP ACYCLOVIR 200 MG CAPSULES ACYCLOVIR 400 MG TABLETS ACYCLOVIR 800 MG TABLETS 30 90
Antibiotics Qty* DRUG NAME $0.00 Copay $ 4.00 $ 10.00 AMOXICILLIN 125 MG/5 ML (150 ML BOTTLE) 150 AMOXICILLIN 125 MG/5 ML (100 ML BOTTLE) 100 AMOXICILLIN 125 MG/5 ML (80 ML BOTTLE) 80 AMOXICILLIN 200 MG/5
High-Cost Drug Exclusions
Pharmacy Services High-Cost Exclusions The high cost medications listed below are excluded from coverage because lower cost similar alternatives are available. To help you get the best health benefit at
Everyday Low Cost Generics
Antibiotics Antifungal Antiviral Arthritis/ Pain 30 Day Qty* Free AMOXICILLIN 125 MG/5 ML (150 ML BOTTLE) AMOXICILLIN 125 MG/5 ML (100 ML BOTTLE) AMOXICILLIN 125 MG/5 ML (80 ML BOTTLE) AMOXICILLIN 200
Step Therapy Requirements
An Independent Licensee of the Blue Cross and Blue Shield Association Step Therapy Requirements Effective: 12/01/2017 Updated 11/2017 H0302_2_2014 CMS Accepted 05/05/2014 1 ABILIFY Abilify 10 mg tablet
DT Description Price Category Price change Percentage BNF 1.2 Mebeverine 135mg tablets (100) 759 M %
June 2016 On 13th May, the DH announced that there would be reductions to Category M prices from June until September. http://psnc.org.uk/our-news/contractor-notice-category-m-price-reduction/ This has
Cash Wise Pharmacy $4 GENERIC MEDICATION FORMULARY. Cash Wise Pharmacy s $4 generic medication formulary is sorted by medical condition.
Cash Wise Pharmacy $4 GENERIC MEDICATION FORMULARY Cash Wise Pharmacy s $4 generic medication formulary is sorted by medical condition. 30- day 90- day 30- day 90- day quantity quantity quantity quantity
ACYCLOVIR OINT (CCHP2017)
ACYCLOVIR OINT (CCHP2017) acyclovir 5 % topical ointment Step Therapy requires trial of one (1) of the following: oral generic acyclovir, oral generic famciclovir, oral generic valacyclovir. 1 ALPHAGAN
2016 Step Therapy (ST) Criteria
2016 Step Therapy (ST) Some drugs require step therapy pre-approval. This means that your doctor must have you first try a different drug to treat your medical condition before we will cover a drug that
FORMULARY Revised January 2019
MEDICATION STRENGTH NOTES ANTIMICROBIALS-ANTIBIOTICS AMOXICILLIN CAPS 500 MG AMOXICILLIN SUSP 125 MG/5 ML 250 MG/5 ML 400 MG/5 ML AMOXICILLIN CHEW 250 MG AMOXICILLIN AND CLAVULANIC ACID CAPS (AUGMENTIN)
LET S TALK PREVENTION
LET S TALK PREVENTION YOUR NO-COST PRESCRIPTION DRUGS FOR PREVENTIVE CARE Your health plan offers certain preventive service benefits at no cost to you. This means you don t have to pay a copay* or coinsurance,
March 2017 Pharmacy & Therapeutics Committee Decisions
UCare s Pharmacy and Therapeutics Committee (P&T) is a group of physicians and pharmacists that meet throughout the year to make changes to the UCare formulary (approved drug list). These changes are reviewed
2015 Chinese Community Health Plan Senior Program (HMO) Step Therapy Criteria Last Updated 11/1/2015
2015 Chinese Community Health Plan Senior Program (HMO) Step Therapy Last Updated 11/1/2015 APLENZIN TAB 174MG, 348MG, 522MG Step Therapy requires trial of bupropion SR or bupropion XL in previous 180
Pharmacy Formulary Updates for January 2019
Pharmacy Formulary Updates for January 2019 To offer a pharmacy benefit that is clinically appropriate and cost effective, we constantly review how we cover prescription medications. Periodic adjustments
UWSP Student Health Service Pharmacy Formulary 1/22/2015
UWSP Student Health Service Pharmacy Formulary 1/22/2015 UWSP Student Health Service Pharmacy Formulary 1/22/2015 Medication Name Strength DosageForm Route Acetaminophen 325 MG Tablet Oral Acetaminophen-Codeine
Step Therapy Criteria
Tier 5 Formulary Step Therapy 2016 Updated: 05/24/2016 Effective: 06/01/2016 What is Step Therapy? Some prescription drugs require step therapy (ST). In some cases, the plan requires you to first try certain
RxBlue 2010 ST Criteria
RxBlue 2010 ST Criteria ANTIDEPRESSANTS - SARAFEM... 10 FLUOXETINE HCL... 10 SARAFEM... 10 SELFEMRA... 10 ANTIDEPRESSANTS- SSRI, SNRI... 11 CELEXA... 11 CITALOPRAM... 11 CYMBALTA... 11 EFFEXOR XR... 11
WellCare s South Carolina Preferred Drug List Update
WellCare s South Carolina Preferred Drug List Update This is a list of changes to our preferred drug list. These are a result of the latest WellCare Pharmacy & Therapeutics meeting held on 09/21/2017.
ANTICONVULSANTS. Details. Step Therapy Criteria Date Effective: April 1, 2019
Step Therapy Date Effective: April 1, 2019 ANTICONVULSANTS APTIOM TABLET 200 MG ORAL APTIOM TABLET 400 MG ORAL APTIOM TABLET 600 MG ORAL APTIOM TABLET 800 MG ORAL BANZEL SUSPENSION 40 MG/ML ORAL BANZEL
PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES
PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES Generic Additions These generic drugs recently became available in the marketplace. When these generic drugs became available, we began covering them at the
Changes to the 2018 BlueCross Secure SM (HMO) & BlueCross Total SM (PPO) Formularies
Changes to the 2018 BlueCross Secure SM (HMO) & BlueCross Total SM (PPO) Formularies BlueCross BlueShield of South Carolina may add or remove drugs from the formulary during the year. If we remove drugs
PORTFOLIO Q October 2015 Availability of products is subject to patent restrictions in countries where applicable patents are in effect 1/6
Abiraterone Tablet 250 mg Q4 2016 Acetylsalicylic Acid Tablet GR 100 mg Available Aciclovir Cream 5% - 2 Grs Available Alendronic Acid Tablet 70 mg Available Amikacin Solution for injection 50 mg/ml; 125mg/ml;
ANTIDEPRESSANTS. Details. Step Therapy 2018 Last Updated: 8/21/2018
ANTIDEPRESSANTS EMSAM PATCH 24 HOUR 12 MG/24HR TRANSDERMAL EMSAM PATCH 24 HOUR 6 MG/24HR TRANSDERMAL EMSAM PATCH 24 HOUR 9 MG/24HR TRANSDERMAL FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR 120 MG ORAL FETZIMA
DT Description Price Category Price change
Tariff T Watch October 2014 Readers are no doubt aware of this quarter's bad news for primary care prescribing allocations: NHS England has d the remuneration mechanism for community pharmacies gaining
Pharmacy Policy Updates-Medicare Advantage
Pharmacy Policy Updates-Medicare Advantage The following recommendations included on this update have been approved by the Pharmacy and Therapeutics Committee. Please note: For Medicare Advantage plans
2018 Medicare Part D Formulary Change
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
ANTIEMETICS STEP. Step Therapy Requirements Effective April 1, 2019
Step Therapy Requirements Effective April 1, 2019 ANTIEMETICS STEP Sancuso 3.1 mg/24 hour transdermal patch Zuplenz 4 mg oral soluble film Zuplenz 8 mg oral soluble film COVERAGE OF CERTAIN BRAND NAME
ALOGLIPTIN STEP. Details. Step Therapy Requirements Effective November 1, 2017
ALOGLIPTIN STEP alogliptin 12.5 mg tablet alogliptin 12.5 mg-metformin 1,000 mg tablet alogliptin 12.5 mg-metformin 500 mg tablet alogliptin 12.5 mg-pioglitazone 15 mg tablet alogliptin 12.5 mg-pioglitazone
There have been no updates to the Aetna Better Health of MI formulary for February
AETNA BETTER HEALTH Formulary Change(s) The following updates will be made to the Aetna Better Health of MI formulary on April 1, 2018 Drug Name, Strength, Dosage Form BUTALBIT-ACETAMINOPHEN-CAFF CP CELECOXIB
Alaska Medicaid 90 Day** Generic Prescription Medication List
1 ACYCLOVIR 200 MG CAPSULE BUPROPION HCL 150 MG TAB ER 24H ACYCLOVIR 200 MG/5ML BUPROPION HCL 150 MG TABLET ER ACYCLOVIR 400 MG TABLET BUPROPION HCL 150 MG TABLET ER ACYCLOVIR 800 MG TABLET BUPROPION HCL