Medicare Part D 2016 Formulary Changes Desert Preferred Choice
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- Terence May
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1 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, 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 VERSION: FORMULARY ADDITIONS UPDATE AS OF APRIL 1, 2016: FORMULARY ID: Formulary additions, reductions in preferred or tiered cost-sharing status, or removal of to an existing formulary drug Covered Drug Name of Tier EMPLICITI INJ 400MG ADDITION 5 ELOTUZUMAB HUMIRA PEDIA INJ CROHNS ADDITION 5, QL (8 ADALIMUMAB HUMIRA PEDIA INJ CROHNS ADDITION 5, QL (8 ADALIMUMAB HUMIRA PEN INJ 40MG/0.8 ADDITION 5, QL (8 ADALIMUMAB INVEGA TRINZ INJ 273MG PALIPERIDONE ADDITION 5 QL (1 PER 90 DAYS) 1
2 of Tier INVEGA TRINZ INJ 410MG PALIPERIDONE ADDITION 5 QL (1 PER 90 DAYS) INVEGA TRINZ INJ 546MG PALIPERIDONE ADDITION 5 QL (1 PER 90 DAYS) INVEGA TRINZ INJ 819MG PALIPERIDONE ADDITION 5 QL (1 PER 90 DAYS) LOMUSTINE CAP 40MG LOMUSTINE DELETION 4 LOMUSTINE CAP 100MG LOMUSTINE DELETION 4 LOMUSTINE CAP 10MG LOMUSTINE DELETION 4 MEMANTINE HC SOL 2MG/ML NAMENDA ADDITION 2 QL (360 PER 30 DAYS) PHENYTOIN EX CAP 200MG DILANTIN ADDITION 2 PHENYTOIN EX CAP 300MG DILANTIN ADDITION 2 TRIAMCINOLON AER 55MCG/AC NASACORT DELETION 2 QL (33 PER 30 DAYS) VIBERZI TAB 100MG ELUXADOLINE ADDITION 5 QL (60 PER 30 DAYS) VIBERZI TAB 75MG ELUXADOLINE ADDITION 5 QL (60 PER 30 DAYS) VIIBRYD KIT STARTER VILAZODONE ADDITION 4 ABILIFY DISC TAB 10MG ARIPIPRAZOLE DELETION 3/1/ QL (90 PER 30 DAYS) ALECENSA CAP 150MG ALECTINIB ADDITION 3/1/ QL (240 PER 30 DAYS) ALMOTRIP MAL TAB 12.5MG AXERT ADDITION 3/1/ QL (12 PER 30 DAYS) ALMOTRIP MAL TAB 6.25MG AXERT ADDITION 3/1/ QL (12 PER 30 DAYS) ALOSETRON TAB 0.5MG LOTRONEX ADDITION 3/1/2016 2, QL (60 PER 30 DAYS) ALOSETRON TAB 1MG LOTRONEX ADDITION 3/1/2016 2, QL (60 PER 30 DAYS) ARIPIPRAZOLE TAB 10MG ABILIFY ADDITION 3/1/ QL (90 PER 30 DAYS) ARIPIPRAZOLE TAB 10MG ODT ABILIFY ADDITION 3/1/ QL (90 PER 30 DAYS) ARIPIPRAZOLE TAB 15MG ABILIFY ADDITION 3/1/ QL (60 PER 30 DAYS) ARIPIPRAZOLE TAB 15MG ODT ABILIFY ADDITION 3/1/ QL (60 PER 30 DAYS) 2
3 of Tier ARIPIPRAZOLE TAB 20MG ABILIFY ADDITION 3/1/ QL (60 PER 30 DAYS) ARIPIPRAZOLE TAB 2MG ABILIFY ADDITION 3/1/ QL (450 PER 30 DAYS) ARIPIPRAZOLE TAB 30MG ABILIFY ADDITION 3/1/ QL (30 PER 30 DAYS) ARIPIPRAZOLE TAB 5MG ABILIFY ADDITION 3/1/ QL (180 PER 30 DAYS) AVASTIN INJ 400/16ML BEVACIZUMAB ADDITION 3/1/ BEXAROTENE CAP 75MG TARGRETIN ADDITION 3/1/ BIMATOPROST SOL 0.03% BIMATOPROST ADDITION 3/1/ BREO ELLIPTA INH FLUTICASONE AND VILANTEROL ADDITION 3/1/ QL (60 PER 30 DAYS) CEFIXIME SUS 100/5ML SUPRAX ADDITION 3/1/ CEFIXIME SUS 200/5ML SUPRAX ADDITION 3/1/ COTELLIC TAB 20MG COBIMETINIB ADDITION 3/1/ QL (63 CYRAMZA INJ 100/10ML RAMUCIRUMAB ADDITION 3/1/ CYRAMZA INJ 500/50ML RAMUCIRUMAB ADDITION 3/1/ DARZALEX SOL 100MG/5ML DARATUMUMAB ADDITION 3/1/ DUTASTERIDE CAP 0.5MG AVODART ADDITION 3/1/ QL (30 PER 30 DAYS) EMPLICITI INJ 300MG ELOTUZUMAB ADDITION 3/1/ ENTRESTO TAB 24-26MG SACUBITRIL AND VALSARTAN ADDITION 3/1/ QL (60 PER 30 DAYS) ENTRESTO TAB 49-51MG SACUBITRIL AND VALSARTAN ADDITION 3/1/ QL (60 PER 30 DAYS) ENTRESTO TAB MG SACUBITRIL AND VALSARTAN ADDITION 3/1/ QL (60 PER 30 DAYS) 3
4 of Tier ENVARSUS XR TAB 0.75MG ENVARSUS XR TAB 1MG TACROLIMUS EXTENDED- RELEASE TABLETS ADDITION 3/1/ TACROLIMUS EXTENDED- RELEASE TABLETS ADDITION 3/1/ ENVARSUS XR TAB 4MG TACROLIMUS EXTENDED- RELEASE TABLETS ADDITION 3/1/ FLUVASTATIN TAB 80MG ER LESCOL XL ADDITION 3/1/ QL (30 PER 30 DAYS) FOSCARNET INJ 24MG/ML FOSCARNET DELETION 3/1/ GENVOYA TAB ELVITEGRAVIR, COBICISTAT, EMTRICITABINE, AND TENOFOVIR ALAFENAMIDE ADDITION 3/1/ QL (30 PER 30 DAYS) GLATOPA INJ 20MG/ML GLATIRAMER ACETATE ADDITION 3/1/2016 5, QL (30 PER 30 DAYS) GLEOSTINE CAP 5MG LOMUSTINE ADDITION 3/1/ HYPERRAB S/D INJ 150/ML RABIES IMMUNE GLOBULIN ADDITION 3/1/ HYPERRAB S/D INJ 150/ML RABIES IMMUNE GLOBULIN ADDITION 3/1/ IPOL INJ INACTIVE POLIOVIRUS VACCINE DELETION 3/1/ IRESSA TAB 250MG GEFITINIB ADDITION 3/1/ QL (30 PER 30 DAYS) KEYTRUDA INJ 100MG/4ML PEMBROLIZUMAB ADDITION 3/1/
5 of Tier LEVOTHYROXINE TAB 100MCG SYNTHROID TIER REDUCTION 3/1/ LEVOTHYROXINE TAB 112MCG SYNTHROID TIER REDUCTION 3/1/ LEVOTHYROXINE TAB 125MCG SYNTHROID TIER REDUCTION 3/1/ LEVOTHYROXINE TAB 137MCG SYNTHROID TIER REDUCTION 3/1/ LEVOTHYROXINE TAB 150MCG SYNTHROID TIER REDUCTION 3/1/ LEVOTHYROXINE TAB 175MCG SYNTHROID TIER REDUCTION 3/1/ LEVOTHYROXINE TAB 200MCG SYNTHROID TIER REDUCTION 3/1/ LEVOTHYROXINE TAB 25MCG SYNTHROID TIER REDUCTION 3/1/ LEVOTHYROXINE TAB 300MCG SYNTHROID TIER REDUCTION 3/1/ LEVOTHYROXINE TAB 50MCG SYNTHROID TIER REDUCTION 3/1/ LEVOTHYROXINE TAB 75MCG SYNTHROID TIER REDUCTION 3/1/ LEVOTHYROXINE TAB 88MCG SYNTHROID TIER REDUCTION 3/1/ LINEZOLID TAB 600MG ZYVOX ADDITION 3/1/2016 5, QL (28 PER 14 DAYS) LONSURF TAB TRIFLURIDINE AND TIPIRACIL ADDITION 3/1/ QL (110 LONSURF TAB TRIFLURIDINE AND TIPIRACIL ADDITION 3/1/ QL (80 MEGESTROL SUS 625MG/5ML MEGACE ES ADDITION 3/1/ MEMANT TITRA PAK 5-10MG NAMENDA ADDITION 3/1/ QL (60 PER 30 DAYS) MEMANTINE TAB HCL 10MG NAMENDA ADDITION 3/1/ QL (60 PER 30 DAYS) MEMANTINE TAB HCL 5MG NAMENDA ADDITION 3/1/ QL (60 PER 30 DAYS) METHLPHENIDA CHW 2.5MG METHYLIN ADDITION 3/1/ METHYLPHENID CHW 10MG METHYLIN ADDITION 3/1/ METHYLPHENID CHW 5MG METHYLIN ADDITION 3/1/ METOCLOPRAM TAB 5MG ODT METOZOLV ADDITION 3/1/ MOLINDONE TAB HCL 10MG MOLINDONE ADDITION 3/1/
6 of Tier MOLINDONE TAB HCL 25MG MOLINDONE ADDITION 3/1/ MOLINDONE TAB HCL 5MG MOLINDONE ADDITION 3/1/ MEMANTINE AND NAMZARIC CAP 14-10MG DONEPEZIL ADDITION 3/1/ MEMANTINE AND NAMZARIC CAP 28-10MG DONEPEZIL ADDITION 3/1/ NAPROXEN SOD TAB 375MG CR NAPRELAN ADDITION 3/1/ NAPROXEN SOD TAB 500MG CR NAPRELAN ADDITION 3/1/ NEUMEGA INJ 5MG OPRELVEKIN DELETION 3/1/2016 5, QL (21 PER 21 DAYS) NEVIRAPINE TAB 100MG VIRAMUNE XR ADDITION 3/1/ QL (120 PER 30 DAYS) NINLARO CAP 2.3MG IXAZOMIB ADDITION 3/1/ QL (3 NINLARO CAP 3MG IXAZOMIB ADDITION 3/1/ QL (3 NINLARO CAP 4MG IXAZOMIB ADDITION 3/1/ QL (3 ODOMZO CAP 200MG SONIDEGIB ADDITION 3/1/ QL (30 PER 30 DAYS) OTREXUP INJ 20MG METHOTREXATE ADDITION 3/1/ OTREXUP INJ 25MG METHOTREXATE ADDITION 3/1/ OTREXUP INJ 7.5/0.4 METHOTREXATE ADDITION 3/1/ OTREXUP INJ 10MG METHOTREXATE ADDITION 3/1/ OTREXUP INJ 15MG METHOTREXATE ADDITION 3/1/ PALIPERIDONE TAB ER 1.5MG INVEGA ADDITION 3/1/ QL (240 PER 30 DAYS) PALIPERIDONE TAB ER 3MG INVEGA ADDITION 3/1/ QL (120 PER 30 DAYS) PALIPERIDONE TAB ER 6MG INVEGA ADDITION 3/1/ QL (60 PER 30 DAYS) 6
7 of Tier PALIPERIDONE TAB ER 9MG INVEGA ADDITION 3/1/ QL (60 PER 30 DAYS) PHENOXYBENZA CAP 10MG DIBENZYLINE ADDITION 3/1/ PHENYTOIN EX CAP 200MG DILANTIN DELETION 3/1/ PHENYTOIN EX CAP 300MG DILANTIN DELETION 3/1/ PIMOZIDE TAB 1MG ORAP ADDITION 3/1/ PIMOZIDE TAB 2MG ORAP ADDITION 3/1/ PRALUENT INJ 150MG/ML ALIROCUMAB ADDITION 3/1/2016 5, QL (2 PRALUENT INJ 75MG/ML ALIROCUMAB ADDITION 3/1/2016 5, QL (2 PRALUENT INJ 150MG/ML ALIROCUMAB ADDITION 3/1/2016 5, QL (2 PRALUENT INJ 75MG/ML ALIROCUMAB ADDITION 3/1/2016 5, QL (2 PYRIDOSTIGMI TAB 180MG MESTINON ADDITION 3/1/ QUADRACEL INJ DIPHTHERIA AND TETANUS TOXOIDS, ACELLULAR PERTUSSIS, AND POLIOVIRUS VACCINE ADDITION 3/1/ REPATHA SURE INJ 140MG/ML EVOLOCUMAB ADDITION 3/1/2016 5, QL (3 7
8 of Tier, QL (3 REPATHA INJ 140MG/ML EVOLOCUMAB ADDITION 3/1/ REXULTI TAB 0.25MG BREXPIPRAZOLE ADDITION 3/1/ QL (480 PER 30 DAYS) REXULTI TAB 0.5MG BREXPIPRAZOLE ADDITION 3/1/ QL (240 PER 30 DAYS) REXULTI TAB 1MG BREXPIPRAZOLE ADDITION 3/1/ QL (120 PER 30 DAYS) REXULTI TAB 2MG BREXPIPRAZOLE ADDITION 3/1/ QL (60 PER 30 DAYS) REXULTI TAB 3MG BREXPIPRAZOLE ADDITION 3/1/ QL (30 PER 30 DAYS) REXULTI TAB 4MG BREXPIPRAZOLE ADDITION 3/1/ QL (30 PER 30 DAYS) RISEDRON SOD TAB 35MG DR ATELVIA ADDITION 3/1/ RISEDRONATE TAB 30MG ACTONEL ADDITION 3/1/ QL (5 PER 30 DAYS) RISEDRONATE TAB 35MG ACTONEL ADDITION 3/1/ QL (5 PER 30 DAYS) RISEDRONATE TAB 35MG ACTONEL ADDITION 3/1/ QL (5 PER 30 DAYS) RISEDRONATE TAB 5MG ACTONEL ADDITION 3/1/ QL (30 PER 30 DAYS) RIVASTIGMINE DIS 13.3/24 EXELON ADDITION 3/1/ QL (30 PER 30 DAYS) RIVASTIGMINE DIS 4.6MG/24 EXELON ADDITION 3/1/ QL (30 PER 30 DAYS) RIVASTIGMINE DIS 9.5MG/24 EXELON ADDITION 3/1/ QL (30 PER 30 DAYS) SILDENAFIL INJ REVATIO ADDITION 3/1/ SOMATULINE INJ 120/.5ML LANREOTIDE REMOVED 3/1/ SOMATULINE INJ 60/0.2ML LANREOTIDE REMOVED 3/1/ SOMATULINE INJ 90/0.3ML LANREOTIDE REMOVED 3/1/ STIOLTO AER RESPIMAT TIOTROPIUM AND OLODATEROL ADDITION 3/1/ TAGRISSO TAB 40MG OSIMERTINIB ADDITION 3/1/ QL (60 PER 30 DAYS) TAGRISSO TAB 80MG OSIMERTINIB ADDITION 3/1/ QL (30 PER 30 DAYS) 8
9 of Tier TESTOSTERONE GEL 1% (25MG) ANDROGEL ADDITION 3/1/ QL (300 PER 30 DAYS) TESTOSTERONE GEL 1% (50MG) ANDROGEL ADDITION 3/1/ QL (300 PER 30 DAYS) TESTOSTERONE GEL PUMP 1% ANDROGEL ADDITION 3/1/ QL (300 PER 30 DAYS) TETRABENAZIN TAB 12.5MG XENAZINE ADDITION 3/1/2016 5, QL (240 PER 30 DAYS) TETRABENAZIN TAB 25MG XENAZINE ADDITION 3/1/2016 5, QL (120 PER 30 DAYS) THIOTEPA INJ 15MG THIOTEPA ADDITION 3/1/ TICLOPIDINE TAB 250MG TICLOPIDINE DELETION 3/1/2016 2, QL (60 PER 30 DAYS) TOLAK CRE 4% FLUOROURACIL ADDITION 3/1/ TOLCAPONE TAB 100MG TASMAR ADDITION 3/1/ TOUJEO SOLO INJ 300IU/ML INSULIN GLARGINE ADDITION 3/1/ TRANDO/VERAP TAB CR TARKA ADDITION 3/1/ TRANDO/VERAP TAB CR TARKA ADDITION 3/1/ TRANDO/VERAP TAB CR TARKA ADDITION 3/1/ TRANDO/VERAP TAB CR TARKA ADDITION 3/1/ TRIMIPRAMINE CAP 100MG SURMONTIL ADDITION 3/1/ TRIMIPRAMINE CAP 25MG SURMONTIL ADDITION 3/1/ TRIMIPRAMINE CAP 50MG SURMONTIL ADDITION 3/1/ VIIBRYD KIT VILAZODONE DELETION 3/1/ ZARXIO INJ 300/0.5 FILGRASTIM-SNDZ ADDITION 3/1/ ZARXIO INJ 480/0.8 FILGRASTIM-SNDZ ADDITION 3/1/
10 of Tier LEVOTHYROXINE TAB 25MCG LEVOTHYROXINE TIER REDUCTION 1/1/ LEVOTHYROXINE TAB 50MCG LEVOTHYROXINE TIER REDUCTION 1/1/ LEVOTHYROXINE TAB 75MCG LEVOTHYROXINE TIER REDUCTION 1/1/ LEVOTHYROXINE TAB 88MCG LEVOTHYROXINE TIER REDUCTION 1/1/ LEVOTHYROXINE TAB 100MCG LEVOTHYROXINE TIER REDUCTION 1/1/ LEVOTHYROXINE TAB 112MCG LEVOTHYROXINE TIER REDUCTION 1/1/ LEVOTHYROXINE TAB 125MCG LEVOTHYROXINE TIER REDUCTION 1/1/ LEVOTHYROXINE TAB 137MCG LEVOTHYROXINE TIER REDUCTION 1/1/ LEVOTHYROXINE TAB 150MCG LEVOTHYROXINE TIER REDUCTION 1/1/ LEVOTHYROXINE TAB 175MCG LEVOTHYROXINE TIER REDUCTION 1/1/ LEVOTHYROXINE TAB 200MCG LEVOTHYROXINE TIER REDUCTION 1/1/ LEVOTHYROXINE TAB 300MCG LEVOTHYROXINE TIER REDUCTION 1/1/
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