TABLE OF CONTENTS (Click on a link below to view the section.)
|
|
- Kelley Hodge
- 5 years ago
- Views:
Transcription
1 Follow the links below to access the complete formularies for Plans: Health Plan Acne Allergy Allergic Anaphylactic Reaction Allergic Conjunctivitis Allergic Rhinitis Asthma Atopic Dermatitis Behavioral Health TABLE OF CONTENTS (Click on a link below to view the section.) Anxiety Disorders & Depression Attention Deficit Hyperactivity Disorder Diabetes Gastroesophageal Reflux Head Lice Hormonal Contraception Oral Antibiotics Otic Antibiotics
2 Benzoyl Peroxide (BPO ) Clindamycin Phosphate (Cleocin-T ) Erythromycin Adapalene (Differin ) Tretinoin (Retin-A ) Benzoyl Peroxide/ Erythromycin (Benzamycin ) Clindamycin/ Benzoyl Peroxide 2.5%, 5%, 10% Gel or Liquid ACNE Topical Anti-bacterials $14 1% Gel, 1% Solution $82 1% Lotion $122 2% Gel $133 PA 2% Solution $43 0.3% Gel, 0.1% Cream, 0.1% Lotion (Rx) $433 PA cream only PA PA PA 0.1% Gel (OTC) $169 PA PA 0.025%, 0.05% 0.1% Cream; 0.01%, 0.025% Gel Topical Retinoids Topical Combinations $170 PA 5-3% Gel $199 PA PA 1-5% Gel (Benzaclin ) $396 PA PA PA PA 1.2-5% Gel (Duac ) $245 PA PA PA PA
3
4 Doxycycline monohydrate Minocycline Isotretinoin (Claravis, Myorisan, Zenatane ) ACNE (CONTINUED) Oral Antibiotics 50 mg, 100 mg (capsule preferred) 50 mg, 75 mg, 100 mg (capsule preferred) Oral Retinoids $47 PA PA PA $73 Capsule 10mg-40mg $426 PA PA PA PA PA PA
5 EpiPen 0.3mg/0.3mL, 0.15mg/0.15mL $651 EpiPen Jr. 0.15mg/0.3ml PA Auvi-Q Adrenaclick 0.3mg/0.3mL, 0.15mg/0.15mL 0.3mg/0.3mL, 0.15mg/0.15mL $4,815 PA PA PA PA PA PA $423 PA PA PA Azelastine 0.05% $89 PA PA Cromolyn 4% $24 Ketotifen (Alaway, Zatidor ) ALLERGIC ANAPHYLACTIC REACTION Epinephrine Auto-injector ALLERGIC CONJUNCTIVITIS Ophthalmic Antihistamines 0.025% $9 PA
6 Cetirizine (Zyrtec ) Fexofenadine (Allegra ) Loratadine (Claritin ) 5, 10 mg $14 1 mg/ml $8 30 mg/5 ml $8 PA PA PA PA 60 mg, 180 mg $22 PA PA 180 mg 10 mg $5 1 mg/ml $7 5 mg Chew $24 PA Azelastine 0.15%, 0.1% $119 PA Budesonide (Rhinocort Allergy) 32 mcg/act $14 PA PA PA PA Flunisolide 25 mcg/act $59 PA Fluticasone (Flonase ) Triamcinolone (Nasacort ) ALLERGIC RHINITIS Oral Antihistamines Nasal Antihistamines Nasal Steroids 50 mcg/act $19 55 mcg/act $15 PA PA PA
7 Albuterol Solution 2.5 mg/3 ml $31 Albuterol (Preferred: Ventolin HFA) Beclomethasone dipropionate (Qvar HFA) Budesonide (Pulmicort Flexhaler ) Budesonide (Pulmicort Respules ) Flunisolide (Aerospan HFA) No dose counter Fluticasone furoate (Arnuity Ellipta ) Fluticasone propionate (Flovent Diskus ) Fluticasone propionate (Flovent HFA) ASTHMA Beta-2 Adrenergic Agonists 90 mcg/act $56 Inhaled Corticosteroids 40 mcg/act, 80 mcg/act $196 PA PA > 8 yo PA 90 mcg, 180 mcg DPI $202 PA PA PA PA 0.25 mg/2 ml, 0.5 mg/2ml, 1 mg/2ml $ yo < 4 yo 80 mcg/act $209 PA PA PA PA 100 mcg DPI, 200 mcg DPI 50 mcg DPI, 100 mcg DPI, 250 mcg DPI 44 mcg/act, 110 mcg/act, 220 mcg/act $199 PA PA PA PA $245 PA PA PA $278 PA PA PA
8 Mometasone furoate (Asmanex HFA) Mometasone furoate (Asmanex Twisthaler ) Budesonide/formoterol (Symbicort ) Fluticasone/salmeterol (Advair Diskus ) Fluticasone/salmeterol (Advair HFA ) Mometasone/formoterol (Dulera HFA) Montelukast (Singulair ) 100 mcg/act, 200 mcg/act ASTHMA (CONTINUED) Inhaled Corticosteroids (Continued) $208 PA PA PA 110 mcg, 220 mcg MDI $179 PA PA PA Inhaled Beta-2 Adrenergic Agonist/Corticosteroid mcg/act, mcg/act mcg, mcg, mcg DPI mcg/act, mcg/act, 45-21mcg/act mcg/act,200-5 mcg/act $322 PA PA $402 PA Leukotriene Receptor Antagonists 4 mg (Oral packet), 4, 5 mg (Chew), 10 mg (Tablet) PA PA PA $259 PA PA PA PA PA $310 $55
9 Hydrocortisone External Aclometasone (Aclovate ) Betamethasone valerate (Diprolene External) Fluocinolone acetate (Synalar ) Triamcinolone acetonide (Kenalog ) Betamethasone valerate (Diprolene External) Fluocinolone acetate (Synalar ) Fluticasone propionate (Cutivate External) Mometasone furoate (Elocon External) Triamcinolone acetonide (Kenalog ) ATOPIC DERMATITIS Class 7 Topical Corticosteroids-Least Potent 0.5%, 0.1%, 2.5% Cream and Ointment; 1% Lotion $6 Class 6 Topical Corticosteroids-Mild Potency 0.05% Cream, Ointment $23 PA PA 0.1% Lotion $ % Cream $ % Cream; 0.025% Lotion $20 Class 5 Topical Corticosteroids-Lower Mid Potency 0.1% Cream, Ointment $ % Cream, Ointment 0.005% Ointment; 0.05% Cream $31 $31 0.1% Cream, Lotion $ % Ointment $6 Classes 1-4 topical corticosteroids are not listed since most patients are treated with classes 5-7 topical corticosteroids.
10 Escitalopram (Lexapro ) Fluoxetine (Prozac ) Sertraline (Zoloft ) Dexmethylphenidate Immediate Release (Focalin ) Dexmethylphenidate Long-Acting (Focalin XR ) 5, 10, 20 mg $8 10, 20, 40, 60 mg (capsules preferred) ANXIETY DISORDERS/DEPRESSION Selective Serotonin Reuptake Inhibitors $10 25, 50, 100 mg $6 ATTENTION DEFICIT/HYPERACTIVITY DISORDER (ADHD) Stimulants 2.5, 5, 10 mg $52 5, 10, 15, 20, 30, 40 mg $212 PA PA 25 and 35 mg brand only $395 PA PA PA PA PA Dextroamphetamine- Amphetamine Immediate Release (Adderall ) Dextroamphetamine- Amphetamine Long- Acting (Adderall XR ) 5, 7.5, 10, 12.5, 15, 20, 30 mg $34 5, 10, 15, 20, 25, 30 mg $158
11 Lisdexamfetamine (Vyvanse ) Methylphenidate Immediate Release (Ritalin ) Methylphenidate 10, 20, 30, 40, 50, 60, 70 mg ATTENTION DEFICIT/HYPERACTIVITY DISORDER (ADHD) (CONTINUED) Stimulants (Continued) Long-Acting (Concerta ) Methylphenidate Long- Acting (Metadate CD ) Methylphenidate Long-Acting (Ritalin LA ) Atomoxetine (Strattera ) Clonidine (Catapres ) Clonidine Extended Release (Kapvay ) Guanfacine (Tenex ) Guanfacine ER (Intuniv ) $290 PA PA PA 5, 10, 20 mg $56 PA 18, 27, 36, 54 mg $292 PA 10, 20, 30, 40, 50, 60 mg $ mg $293 PA PA PA 20, 30, 40 mg $179 PA 10, 18, 25, 40, 60, 80, 100 mg Non-Stimulants $454 PA PA PA PA 0.1 mg, 0.2 mg, 0.3 mg $ mg $285 PA PA PA PA 1, 2 mg $26 1, 2, 3, 4 mg $37 PA PA
12 Insulin degludec (Tresiba ) Insulin detemir (Levemir ) Insulin glargine (Basaglar ) Insulin glargine (Lantus ) Insulin aspart protamine/insulin aspart (Novolog ) Insulin NPH/insulin regular (Humulin 70/30 ) Insulin NPH/insulin regular (Novolin 70/30 ) 100, 200 units/ml Flextouch pen (3mL/pen) Diabetes Long Acting Insulin $427 PA PA PA PA PA 100 units/ml vial $288 PA PA PA PA PA 100 units/ml Flextouch pen (3mL/pen) 100 units/ml Kwikpen (3mL/pen) $259 PA PA PA PA PA $203 PA 100 units/ml vial $266 PA PA PA PA PA 100 units/ml Solostar pen (3mL/pen) $239 PA PA PA PA PA 100 units/ml vial $ units/ml Flexpen (3mL/pen) $342 PA PA 100 units/ml vial $148 PA 100 units/ml Kwikpen (3mL/pen) Mixed Insulin $281 PA PA PA 100 units/ml vial $147 PA
13 Insulin NPH (Humulin N) Insulin NPH (Novolin N) Insulin aspart (Novolog ) Insulin glulisine (Apidra ) Insulin lispro (Humalog ) Insulin regular (Humulin R ) Insulin regular (Novolin R ) 100 units/ml vial $148 PA 100 units/ml Kwikpen (3mL/pen) $281 PA PA PA Diabetes Intermediate Acting Insulin 100 units/ml vial $147 PA Short Acting Insulin 100 units/ml vials $ units/ml Flexpen (3mL/pen) $342 PA 100 units/ml vial $273 PA PA PA 100 units/ml Solostar pen (3mL/pen) $316 PA PA 100 units/ml vial $ units/ml Kwikpen (3mL/pen) $316 PA PA 100 units/ml vial $148 PA 100 units/ml vial $147 PA
14 Famotidine (Pepcid ) Ranitidine (Zantac ) Esomeprazole (Nexium ) GASTROESOPHAGEAL REFLUX H2 Antihistamines 10, 20, 40 mg $13 40 mg/5ml $154 75, 150, 300 mg $12 15 mg/ml $120 Proton Pump Inhibitors 20 mg, 40 mg $164 PA PA PA PA PA PA 20 mg OTC (Nexium 24HR) $21 PA 15 mg, 30 mg Capsules $61 PA PA PA Lansoprazole (Prevacid ) Omeprazole (Prilosec ) 15 mg OTC (Prevacid 24HR) $24 PA 15, 30 mg Solutabs $444 PA PA PA PA PA PA 3 mg/ml First Lansoprazole $80 PA PA PA PA PA PA 10, 20, 40 mg Capsules $22 PA 2 mg/ml First Omeprazole $69 PA PA PA PA
15 Benzyl alcohol (Ulesfia ) Ivermectin lotion (Sklice ) Malathion lotion (Ovide ) Permethrin (Nix ) Pyrethrins/piperonyl butoxide (LiceMD /RID ) Spinosad suspension (Natroba ) HEAD LICE Topical Pediculocides 5% $218 PA PA PA PA PA PA 0.5% $334 PA PA PA PA PA 0.5% $237 PA PA 1% $ %-4% $7 PA PA 0.9% $263 PA
16 Drospirenone/EE (Yaz ) Levonorgestrel/EE (Aviane ) Norethindrone acetate/ee (Loestrin Fe 1/20) HORMONAL CONTRACEPTION Combined Oral Contraceptives - Monophasic 20 mcg Estrogen Desogestrel/EE (Desogen ) Drospirenone/EE (Yasmin ) Levonorgestrel/EE (Levora ) Norethindrone acetate/ee Norgestrel/EE (Low-Ogestrel ) 3 mg/20 mcg $41 PA PA PA 0.1 mg/20 mcg $25 1 mg/20 mcg $31 Combined Oral Contraceptives - Monophasic 30 mcg Estrogen 0.15 mg/30 mcg $22 3 mg/30 mcg $59 PA PA 0.15 mg/30 mcg $ mg/30 mcg $ mg/30 mcg $25
17 Drospirenone/EE (Yaz ) Levonorgestrel/EE (Aviane ) Norethindrone acetate/ee (Loestrin Fe 1/20) HORMONAL CONTRACEPTION Combined Oral Contraceptives - Monophasic 20 mcg Estrogen Desogestrel/EE (Desogen ) Drospirenone/EE (Yasmin ) Levonorgestrel/EE (Levora ) Norethindrone acetate/ee Norgestrel/EE (Low-Ogestrel ) 3 mg/20 mcg $41 PA PA PA 0.1 mg/20 mcg $25 1 mg/20 mcg $31 Combined Oral Contraceptives - Monophasic 30 mcg Estrogen 0.15 mg/30 mcg $22 3 mg/30 mcg $59 PA PA 0.15 mg/30 mcg $ mg/30 mcg $ mg/30 mcg $25
18
19 Nexplanon (Etonogesterel Implant) Kyleena (Levonorgestrel IUD) Liletta (Levonorgestrel IUD) Mirena (Levonorgestrel IUD) Skyla (Levonorgestrel IUD) 68 mg (Up to 3 years) 19.5 mg (Up to 5 years) 52 mg (Up to 3 years) 52 mg (Up to 5 years) 13.5 mg (Up to 3 years) HORMONAL CONTRACEPTION (CONTINUED) Long-Acting Reversible Contraceptives Other Contraceptives $926 $1,030 PA PA PA PA $750 PA $1,030 $858 Medroxyprogesterone Acetate Injection (Depo-Provera ) 150 mg/ml IM $98 Etonogestrel/EE Vaginal Ring (NuvaRing ) Norelgstromin/EE Patch (Xulane ) mg/24 hrs $ mcg/24 hrs $133 PA PA
20 Amoxicillin Amoxicillin/ Clavulanate (Augmentin ) Augmentin ES (Not interchangeable w ith other suspensions; Target clavulanic acid dose is 6.4mg/kg/day; increased diarrhea at 10mg/kg/day) Amoxicillin/ Clavulanate (Augmentin XR ) Penicillin V Potassium (Pen VK ) Cephalexin (Keflex ) Cefdinir (Omnicef ) ORAL ANTIBIOTICS Penicillins 125, 250 mg chew $16 250, 500 mg capsule $ mg/5ml, 250 mg/5 ml, 400 mg/5 ml 250 mg-62.5 mg/5ml, 400 mg-57 mg/5 ml $9 $ mg-125 mg $ mg-42.9 mg/5ml (high dose amoxicillin only) $102 1,000 mg-62.5 mg $ mg/5mL, 250 mg/5 ml $5 250 mg, 500 mg $15 Cephalosporins 250 mg, 500 mg (capsule preferred) $ mg/5 ml $ mg $ mg/5 ml $75
21
22 Clindamycin (Cleocin ) Metronidazole (Flagyl ) Nitrofurantoin monohydrate Nitrofurantoin (Furadantin ) 75 mg, 150 mg $28 75 mg/5 ml $ , 500 mg $20 ORAL ANTIBIOTICS (CONTINUED) Miscellaneous 100 mg $39 25 mg/5 ml $730
23 Ofloxacin Ciprofloxacin/ dexamethasone (Ciprodex ) Ciprofloxacin (Cetraxal ) OTIC ANTIBIOTICS Otic Anti-infectives 0.3% Floxin Otic $ % Ocuflox Opthl. $85 0.3/0.1% suspension $215 PA PA PA 0.2% solution $99 PA PA PA PA
TABLE OF CONTENTS (Click on a link below to view the section.)
Follow the links below to access the complete formularies for Plans: Health Plan Acne Allergy Allergic Anaphylactic Reaction Allergic Conjunctivitis Allergic Rhinitis Asthma Atopic Dermatitis Behavioral
More informationTABLE OF CONTENTS (Click on a link below to view the section.)
Follow the links below to access the complete formularies for Plans: Buckeye Health Plan Acne Allergy Allergic Anaphylactic Reaction Allergic Conjunctivitis Allergic Rhinitis Asthma Atopic Dermatitis Behavioral
More informationTABLE OF CONTENTS (Click on a link below to view the section.)
Follow the links below to access the complete formularies for Plans: Health Plan Acne Allergy Allergic Anaphylactic Reaction Allergic Conjunctivitis Allergic Rhinitis Asthma Atopic Dermatitis Behavioral
More informationOHIO MEDICAID PHARMACY COVERAGE
OHIO MEDICAID PHARMACY COVERAGE This information is intended for use by providers to help select the most appropriate cost-effective medication and formulation for their patients. Prescribers should utilize
More informationRelative Cost/Month. Less than $10. Loratadine Liquid* $10-$15 Cetirizine liquid 1mg/mL*
Allergy Chlorpheniramine Tablet* Diphenhydramine Tablet* Diphenhydramine Liquid* Loratadine Tablet* Cetirizine Tablet* Loratadine 10mg ODT* Less than $10 Loratadine Liquid* $10-$15 Cetirizine liquid 1mg/mL*
More informationMercy Care Plan. Acyclovir Ointment. Products Affected. acyclovir ointment 5 % external Details. Criteria. Requires use of oral Acyclovir
Acyclovir Ointment Mercy Care Plan acyclovir ointment 5 % external Requires use of oral Acyclovir 1 Adcirca ADCIRCA TABLET 20 MG ORAL Requires use of Sildenafil 2 Albenza ALBENZA TABLET 200 MG ORAL Requires
More informationAetna 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
More informationOregon Health Plan prescription benefit updates
Oregon Health Plan prescription benefit updates EOCCO s prescription program is a pharmacy benefit that offers members a choice of safe and effective medication treatments. The program also helps you save
More informationAlameda Alliance for Health Pharmacy & Therapeutics (P&T) Committee Decisions
Alameda Alliance for Health FORMULARY UPDATE Effective: October 27, 2017. Drugs notated with an * have an undetermined implementation date Alameda Alliance for Health Pharmacy & Therapeutics (P&T) Committee
More informationANTINEOPLASTIC DRUGS CHAPTER 21. Antineoplastic drugs - designed to treat malignancies, now also used to treat diseases with inflammatory component
ANTINEOPLASTIC DRUGS CHAPTER 21 Antineoplastic drugs - designed to treat malignancies, now also used to treat diseases with inflammatory component Tx of malignancies Antineoplastic drugs: methotrexate
More informationMercy Care ALBENDAZOLE. Products Affected. ALBENZA TABLET 200 MG ORAL Details. Criteria. Refer to PA Guideline for approval criteria
ALBENDAZOLE Mercy Care ALBENZA TABLET 200 MG ORAL Refer to PA Guideline for approval criteria 1 BRIMONIDINE-TIMOLOL COMBIGAN SOLUTION 0.2-0.5 % OPHTHALMIC Requires use of separate ingredients for at least
More informationAETNA 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
More informationAETNA 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
More informationStep Therapy Medications
Step Therapy Medications Step Therapy (ST PA ) is an automated form of prior authorization. It encourages the use of therapies that should be tried first, before other treatments are covered, based on
More informationUWSP 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
More informationQuarterly pharmacy formulary change notice
Provider Bulletin June 2017 The formulary changes listed in the table below apply to all Anthem HealthKeepers Plus patients. These changes were reviewed and approved at the first quarter Pharmacy and Therapeutics
More informationStep Therapy Requirements
An Independent Licensee of the Blue Cross and Blue Shield Association Step Therapy Requirements Effective: 05/01/2018 Updated 4/2018 H0302_2_2014 CMS Accepted 05/05/2014 1 BETA-BLOCKERS BYSTOLIC 10 MG
More informationCLINICAL MEDICAL POLICY
CLINICAL MEDICAL POLICY Policy Name: Xolair (omalizumab) Policy Number: MP-051-MD-DE Responsible Department(s): Medical Management; Clinical Pharmacy Provider Notice Date: 10/01/2017 Original Effective
More informationFORMULARY NOTES ABOUT FORMULARY AND PHARMACY
FORMULARY NOTES ABOUT FORMULARY AND PHARMACY 1. Purposes: Assist team leaders in preparing for trips Limit the number of interchangeable drugs Limit pharmacy errors Improve efficiency and organization
More informationFORMULARY 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)
More informationAcyclovir Ointment. Aetna Better Health Pennsylvania. Products Affected. acyclovir ointment 5 % external Details. Criteria
Medications that require Step Therapy (ST) require trial and failure of preferred formulary agents prior to their authorization. If the prerequisite medications have been filled within the specified time
More informationOral Agents. Formulary Limits. Available Strengths. IR: 4mg ER: 12mg Syrup: 2mg/5ml
MEDICATION COVERAGE POLICY PHARMACY AND THERAPEUTICS ADVISORY COMMITTEE POLICY: Seasonal Allergy Medications LAST REVIEW: 9/20/2016 THERAPEUTIC CLASS: Rheumatologic/Immunologic REVIEW HISTORY: 5/16, 5/15,
More informationDrug Class Monograph
Drug Class Monograph Class: Inhaled Corticosteroids Drugs: Aerospan (flunisolide), Advair Diskus, Advair HFA (fluticasone/salmeterol), Alvesco (ciclesonide), Arnuity Ellipta (fluticasone furoate), Asmanex
More informationCAMPER APPLICATION PACKET
CAMPER APPLICATION PACKET Monday- Friday June 12-16, 2017 Rockport, Texas DEADLINE FOR SUBMITTING ALL FORMS: THE IMPORTANCE OF COMPLETING ALL CAMP FORMS Although it may seem like a lot of paperwork, the
More informationDiagnosis and Management of Asthma
Supporting Evidence: Diagnosis and Management of Asthma The subdivision of this section is: Appendix B Tables Copyright 2016 by 1 Eleventh Edition/December 2016 Appendix B Asthma Summary Tables Class:
More informationInhaled bronchodilators relax constricted airways and treat the noisy part of asthma: coughing, wheezing, choking and shortness of breath.
Inhaled bronchodilators relax constricted airways and treat the noisy part of asthma: coughing, wheezing, choking and shortness of breath. AccuNeb inhalation 0.021% solution: 0.63mg/3mL 3-4 times solution
More informationPharmacy Updates Summary
All of the following changes were reviewed and approved by the SFHP Pharmacy & Therapeutics (P&T) Committee on 01/21/2015 Effective date: 02/21/2015 Therapeutic Classes reviewed: Allergen-Specific Immunotherapy
More informationCommissioner for the Department for Medicaid Services Selections for Preferred Products
Commissioner for the Department for Medicaid Services Selections for Preferred Products This is a summary of the final Preferred Drug List (PDL) selections made by the Commissioner for the Department for
More informationClinical Policy: Dupilumab (Dupixent) Reference Number: ERX.SPA.49 Effective Date:
Clinical Policy: (Dupixent) Reference Number: ERX.SPA.49 Effective Date: 06.01.17 Last Review Date: 02.19 Revision Log See Important Reminder at the end of this policy for important regulatory and legal
More informationOral Agents. Fml Limits. Available Strengths NF NF
MEDICATION COVERAGE POLICY PHARMACY AND THERAPEUTICS ADVISORY COMMITTEE POLICY: Allergy Medications LAST REVIEW: 9/12/2017 THERAPEUTIC CLASS: Rheumatologic/Immunologic REVIEW HISTORY: 9/16, 5/15, 9/14
More informationStep Therapy Criteria 2019
Step Therapy 2019 For information on obtaining an updated coverage determination or an exception to a coverage determination please call Freedom Health Member Services at 1-800-401-2740 or, for TTY/TDD
More informationWellCare 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 09/03/2015.
More informationAllergies and Asthma 5/21/2013. Objectives. Allergic Rhinitis (AR): Risk Factor for ASTHMA. Rhinitis and Asthma
Allergies and Asthma Presented By: Dr. Fadwa Gillanders, Pharm.D Clinical Pharmacy Specialist May 2013 Objectives Understand the relationship between asthma and allergic rhinitis Understand what is going
More informationARBS 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
More informationFORMULARY Revised January 2018 NOTES ABOUT FORMULARY AND PHARMACY
FORMULARY Revised NOTES ABOUT FORMULARY AND PHARMACY 1. Purposes: Assist team leaders in preparing for trips Limit the number of interchangeable drugs Limit pharmacy errors Improve efficiency and organization
More informationStep 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
More informationAmitriptyline 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
More informationClinical Policy: Omalizumab (Xolair) Reference Number: ERX.SPA.141 Effective Date: Last Review Date: 08.17
Clinical Policy: (Xolair) Reference Number: ERX.SPA.141 Effective Date: 03.01.14 Last Review Date: 08.17 Revision Log See Important Reminder at the end of this policy for important regulatory and legal
More informationUWSP Student Health Service Pharmacy Formulary updated: 1/2017
UWSP Student Health Service Pharmacy Formulary updated: 1/2017 Medication Name Strength DosageForm Route Acetaminophen 325 MG Tablet Oral Acetaminophen-Codeine #2 300-15 MG Tablet Oral Acetaminophen-Codeine
More informationTriage Information: 1. Duration of HPSJ Membership 2. Age 3. Fill history of Seasonal Allergy Medications
MEDICATION COVERAGE POLICY PHARMACY AND THERAPEUTICS ADVISORY COMMITTEE POLICY: Seasonal Allergy Medications LAST REVIEW: 5/28/2015 THERAPEUTIC CLASS: Rheumatologic/Immunologic REVIEW HISTORY: 5/15, 9/14
More informationMEDICAL ASSISTANCE BULLETIN
ISSUE DATE SUBJECT EFFECTIVE DATE January 20, 2016 MEDICAL ASSISTANCE BULLETIN NUMBER *See Below BY Drug List (PDL) Update January 20, 2016 Pharmacy Services Leesa M. Allen, Deputy Secretary Office of
More informationDrug List exclusions for Blue Cross commercial plans
Drug List exclusions for Blue Cross commercial plans The drugs shown below aren t covered on the commercial Blue Cross Blue Shield of Michigan drug lists. In most cases, if you fill a prescription for
More informationAmitriptyline 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
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Dupixent) Reference Number: CP.PHAR.336 Effective Date: 05.01.17 Last Review Date: 02.19 Line of Business: Commercial, HIM, Medicaid Coding Implications Revision Log See Important Reminder
More informationAdapted from: Best Practices for Medication Management for Children & Adolescents in Foster Care. October 2015
Adapted from: Best Practices for Medication Management for Children & Adolescents in Foster Care October 2015 Psychotropic Medications Key Information Purpose: This document is designed for any reader
More informationALLERGIC RHINITIS-NASAL
ALLERGIC RHINITIS-NASAL FLUNISOLIDE Patient needs to have paid claims for any one of the following Step 1 drugs: NasaCort OTC, fluticasone Rx, fluticasone OTC, Budesonide OTC. Prior to filling the Step
More informationQuarterly 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
More informationQuarterly 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
More informationPHARMA-MEDIC SERVICES INC. POLICY MANUAL
PHARMA-MEDIC SERVICES INC. POLICY MANUAL SUBJECT: INDEX: P.5.a.iii Automatic-Therapeutic Substitution DATE: June 1/2011 REVISED: March 2, 2015., Feb 2017. PROCEDURE: 1. Long term care homes use the Manitoba
More informationPharmacy Updates Summary
All of the following changes were reviewed and approved by the SFHP Pharmacy & Therapeutics (P&T) Committee on 4/16/2014 Effective date: 5/15/2014 Therapeutic Classes reviewed: ADHD Ophthalmic antihistamines
More informationSmithRx Standard Formulary Step Therapy List
SmithRx Standard Formulary Step Therapy List Revised: January 27, 2017 The following medications require prior use of at least one other medication for coverage. Please note that any plan-specific customizations
More informationAPPENDIX 1 Printable point-of-care tables Asthma Action Plan Yellow Zone Formulation Table Region: Europe
APPENDIX 1 Printable point-of-care tables Asthma Action Plan Yellow Zone Formulation Table Region: Europe Instructions: Print on 8.5 x14 (216 x 279 mm) paper (Legal size) Medication in Green Zone Change
More informationQuarterly 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
More informationKey features and changes to these four components of asthma care include:
Guidelines for the Diagnosis and Management of Asthma in Adults Clinical Practice Guideline MedStar Health These guidelines are provided to assist physicians and other clinicians in making decisions regarding
More informationBehavioral Health. Behavioral Health. Prescribing Guidelines
Behavioral Health Behavioral Health Prescribing Guidelines Attention Deficit/Hyperactivity Disorder (ADHD) Start with a first line medication, either from the methylphenidate or dextroamphetamine-amphetamine
More informationInhaled Corticosteroids Drug Class Prior Authorization Protocol
Inhaled Corticosteroids Drug Class Prior Authorization Protocol Line of Business: Medi-Cal P&T Approval Date: February 21, 2018 Effective Date: April 1, 2018 This policy has been developed through review
More informationUpper Peninsula Health Plan Advantage (HMO) (List of Covered Drugs)
Analgesics Opioid Analgesics, Long-acting fentanyl 100 mcg/hr patch td72 morphine sulfate 30 mg tablet er Opioid Analgesics, Short-acting fentanyl citrate 200 mcg lozenge hd hydrocodone/acetaminophen 5
More informationClinical Policy: Omalizumab (Xolair) Reference Number: ERX.SPA.141 Effective Date:
Clinical Policy: (Xolair) Reference Number: ERX.SPA.141 Effective Date: 03.01.14 Last Review Date: 02.18 Revision Log See Important Reminder at the end of this policy for important regulatory and legal
More informationUPDATE WellCare s South Carolina
September 3, 2015 UPDATE WellCare s South Carolina Preferred Drug List Dear Provider: At the September 3, 2015 WellCare Pharmacy & Therapeutics Committee meeting, it was decided that the following changes
More informationBerkshire Allergy & Asthma Center 2210 Ridgewood Road, Suite 100 Wyomissing, PA (610)
Berkshire Allergy & Asthma Center 2210 Ridgewood Road, Suite 100 Wyomissing, PA 19610 (610) 372-0502 It is with pleasure that we welcome you as a new patient to Berkshire Allergy & Asthma Center, a division
More informationInhaled Corticosteroids Drug Class Prior Authorization Protocol
Inhaled Corticosteroids Drug Class Prior Authorization Protocol Line of Business: Medicaid P&T Approval Date: February 21, 2018 Effective Date: April 1, 2018 This policy has been developed through review
More informationCalgary Long Term Care Formulary
Page 1 of 10 Calgary Long Term Care Formulary Pharmacy & Therapeutics November 2018 Highlights https://www.albertahealthservices.ca/info/page4071.aspx Page 2 of 10 Contents November 2018... 3 Formulary
More informationKentucky Medicaid will incorporate the following changes to its PDL on June 11, 2014:
Fee-For-Service Pharmacy Provider Notice #179 April Pharmacy Updates May 22, 2014 11013 W. Broad Street Glen Allen, VA 23060 Dear Kentucky Medicaid Provider: Please be advised that the Department for Medicaid
More informationStep Therapy Criteria (Criteria for Step Therapy-2 [ST-2] Drugs)
CareAdvantage CMC 2018 Formulary Supplement II (List of Covered Drugs) Step Therapy Criteria (Criteria for Step Therapy-2 [ST-2] Drugs) Formulary ID: 00018157 Formulary Version:11 19 CMS Approved: 08/21/2018
More informationRemoved 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
More informationBig Lots Behavioral Health. Prescribing Guidelines for Behavioral Health
Big Lots Behavioral Health Prescribing Guidelines for Behavioral Health Prescribing for Behavioral Health This document was developed by Nationwide Children s Hospital in conjunction with Partners For
More informationInhaled Corticosteroid Dose Comparison in Asthma
This Clinical Resource gives subscribers additional insight related to the Recommendations published in April 2017 ~ Resource #330402 Inhaled Corticosteroid Dose Comparison in Asthma The chart below provides
More informationTRELEGY ELLIPTA (fluticasone-umeclidinium-vilanterol) aerosol powder
TRELEGY ELLIPTA (fluticasone-umeclidinium-vilanterol) aerosol powder Coverage for services, procedures, medical devices and drugs are dependent upon benefit eligibility as outlined in the member's specific
More informationCalgary Long Term Care Formulary
Page 1 of 14 Calgary Long Term Care Formulary Pharmacy & Therapeutics Highlights https://www.albertahealthservices.ca/info/page4071.aspx Page 2 of 14 Contents... 3 Formulary Changes (Additions, Changes,
More informationData Class: Internal. 1 inhaler (30 blisters OR 14 blisters institutional pack) per presciption
To help make the use of prescription drugs safer and more affordable, our plan is now using a Drug Quantity Management program. That is, for certain medications, you can receive an amount to last you a
More informationUpdates to your prescription benefits
Updates to your prescription benefits Effective Jan. 1, 2018 Update Summary Within the Prescription Drug List (PDL), medications are grouped by tier. The tier indicates the amount you pay when you fill
More informationSecretary for Health and Family Services Selections for Preferred Products
Secretary for Health and Family Services Selections for Preferred Products This is a summary of the final Preferred Drug List (PDL) selections made by the Secretary for Health and Family Services based
More informationAlprazolam 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
More informationEffective for all members on August 1, 2017
August 2017 Pharmacy Formulary Change Notice BlueChoice HealthPlan Medicaid is here to help you stay on top of your health care. We want to tell you about some upcoming changes to your Preferred Drug List
More informationJULY 2017 ADDITIONS. NP Thyroid 120mg NP Thyroid 15mg JUNE 2017 CHANGES
APRIL 2017 Ivermectin, Pin-X and Reeses (Pyrantel Pamoate) Selzentry 25mg and 75mg tablets Linzess 72 mcg capsule-with QLL Levalbuterol Tartrate Inhal Aerosol (Generic Xopenex HFA) with ST & QLL Jentadueto
More informationPain Oral-Intranasal Fentanyl (Abstral, Actiq, Fentora, Lazanda, Onsolis, Subsys)
Pennsylvania Employees Benefit Trust Fund (PEBTF) and n- Medicare Eligible Retired Employees Health Program (REHP), Step Therapy and Quantity Limit List Your doctor needs to get prior authorization for
More informationStep Therapy Requirements. Effective: 12/01/2016
Effective: 12/01/2016 H2986_PD_049 Updated 11/2016 ALPHA 1-PROTEINASE INHIBITOR GLASSIA PRIOR CLAIM FOR ARALAST NP OR ZEMAIRA WITHIN THE PAST 120 DAYS. ANALGESICS, NARCOTICS KADIAN MORPHINE SULFATE ER
More informationAetna 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
More informationAD/HD is a mental disorder, and it often lasts from
short version10 WHAT WE KNOW Managing Medication for Adults with AD/HD AD/HD is a mental disorder, and it often lasts from childhood into adulthood. Medication is the basic part of treatment for adults.
More informationBig Lots Behavioral Health. Prescribing Guidelines for Behavioral Health
Big Lots Behavioral Health Prescribing Guidelines for Behavioral Health Prescribing for Behavioral Health This document was developed by Nationwide Children s Hospital in conjunction with Partners For
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: Reference Number: CP.PMA_10.11.7 Effective Date: 07.16 Last Review Date: 04.18 Line of Business: Cenpatico Medicaid Arizona Revision Log See Important Reminder at the end of this policy
More informationAttention: Behavioral Health Providers, Pharmacists and Prescribers N.C. Medicaid and N.C. Health Choice Preferred Drug List Changes - UPDATE
Attention: Behavioral Health Providers, Pharmacists and Prescribers N.C. Medicaid and N.C. Health Choice Drug List Changes - UPDATE Note: This article was previously published in the December 2014 Medicaid
More informationQuarterly pharmacy formulary change notice
Quarterly pharmacy formulary change notice Summary of change: The Pharmacy and Therapeutics Committee (P&T) reviewed and approved the formulary changes listed in the table below on March 29, 2016. What
More informationA Visual Approach to Simplifying Respiratory Drug Regimens
A Visual Approach to Simplifying Respiratory Drug Regimens Stephanie Cheng, PharmD, MPH, BCGP 3 Main Categories Inhaled Respiratory Drugs Binds to beta-2 receptors Relaxation of smooth muscles in the lung
More informationAmerigroup Washington, Inc. to conduct postservice reviews of certain modifiers and services
Provider News Bulletin Amerigroup Washington, Inc. https://providers.amerigroup.com/ Medicaid providers: 1-800-454-3730 Medicare providers: 1-866-805-4589 December 2017 Table of Contents Special Announcement:
More informationMEDICAL ASSISTANCE BULLETIN
ISSUE DATE February 18, 2015 SUBJECT EFFECTIVE DATE January 21, 2015 MEDICAL ASSISTANCE BULLETIN NUMBER *See below BY Drug List (PDL) Update January 21, 2015 Pharmacy Services Vincent D. Gordon, Deputy
More informationThere 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
More informationThe Inflammatory Response. Inflammation in the Airway. The Inflammatory Response. Inflammation in the Airway. Inflammation in the Airway
The Inflammatory Response RSPT 2217 Gardenhire Chapter 11 A general definition inflammation is the response of vascularized tissue to injury First described in the first century A.D. and revised in the
More informationUniversity System of Georgia Prior Authorization, Step Therapy and Quantity Limit List (Updated 1/1/2016)
University System of Georgia, Step Therapy and Quantity Limit List (Updated 1/1/2016) (PA) Your doctor will need to obtain a prior authorization for the drugs listed below, before your prescription drug
More informationCMI Marketplace 2015 (List of Covered Drugs)
Analgesics Opioid Analgesics, Long-acting fentanyl 100 mcg/hr patch td72 fentanyl citrate 200 mcg lozenge hd morphine sulfate 30 mg tablet er oxymorphone hcl 7.5 mg tab er 12h Opioid Analgesics, Short-acting
More informationParents Guide to ADHD Medications. Copyright Child Mind Institute
Copyright 2017. Child Mind Institute Children with attention-deficit hyperactivity disorder (ADHD) find it unusually difficult to concentrate on tasks, to pay attention, to sit still and to control impulsive
More informationClinical Policy: Dupilumab (Dupixent) Reference Number: ERX.SPA.49 Effective Date:
Clinical Policy: (Dupixent) Reference Number: ERX.SPA.49 Effective Date: 06.01.17 Last Review Date: 02.19 Revision Log See Important Reminder at the end of this policy for important regulatory and legal
More informationA Brief Overview of Psychiatric Pharmacotherapy. Joel V. Oberstar, M.D. Chief Executive Officer
A Brief Overview of Psychiatric Pharmacotherapy Joel V. Oberstar, M.D. Chief Executive Officer Disclosures Some medications discussed are not approved by the FDA for use in the population discussed/described.
More informationTHERAPEUTIC AREA NAME STRENGTH DOSAGE FORM
Value Based Tier Drugs are selected for the management of Asthma, Diabetes, Hypertension and Hyperlipidemia. These drugs are covered at no charge or at a reduced cost share. Medications are under continual
More informationADHD Medications Table
Stimulants are the first line treatment of choice for ADHD followed by Non-Stimulants, then off-label medications. We are providing this list of medications so that you can be familiar with the common
More informationShort-acting insulins. Biphasic insulins. Intermediate- and long-acting insulins
Recommended Insulin Products This guideline states the Gloucestershire Joint Formulary recommended, first choice insulin products. The intention is to support the choice of treatment for new patients,
More informationINSULIN OVERVIEW. Type Brand Name Onset Peak Duration Role in glucose management Page Rapid-Acting lispro min. 3-5 hrs min.
INSULIN OVERVIEW Type Brand Name Onset Peak Duration Role in glucose management Page Rapid-Acting lispro Humalog 15-30 min 30-90 min 3-5 hrs aspart glulisine Short-Acting Regular insulin NovoLog Apidra
More information