Future Formulary Changes
|
|
- Teresa Doreen Spencer
- 5 years ago
- Views:
Transcription
1 Future Formulary Changes Applies to: Employer group plan 2019 open formularies with specialty tiers KEY: PA=prior authorization; ST=step therapy; QL=quantity limit Obeticholic acid Ocaliva Limited to Kaiser Dulaglutide Trulicity Add PA Triamcinolone acetonide nasal spray Nasacort Add PA Ivacaftor packet Kalydeco Add QL of 60 units Dichlorphenamide Keveyis Add QL of 120 tablets Adapalene cream 0.1% Differin Move to Tier 3 Clobetasol spray Clobex Ancillary charge Clobetasol shampoo Clobex Ancillary charge Clobetasol lotion Clobex Ancillary charge Tretinoin gel Retin-A, Retin-A Micro Move to Tier 3 Tretinoin cream Retin-A Move to Tier 3 Parathyroid hormone Natpara Add PA 01/07/ /21/2018 Adapalene/benzoyl peroxide gel Epiduo Ancillary charge
2 Estradiol vaginal cream Estrace Move to Tier 3 Desonide cream Desowen Move to Tier 3 Desonide lotion Desowen Move to Tier 3 Dalfampridine ER Ampyra Limited to Kaiser Cabozantinib Cabometyx Limited to Kaiser Liraglutide Victoza Add QL of 3 Dulaglutide Trulicity Add QL of 4 Semaglutide Ozempic Add QL of 2 Exenatide Bydureon Add QL of 4 Exenatide Byetta Add QL of 1 dispensing unit per Lofexidine Lucemyra Add QL of 224 tablets Sapropterin Kuvan Add PA Budesonide Pulmicort Flexhaler Add PA Fluticasone furoate Arnuity Ellipta Add PA Interferon beta-1a Rebif Add PA Beclomethasone dipropionate Qvar; Qvar Redihaler Add PA 12/01/ /12/2018
3 Hydroxyprogesterone caproate Makena Move to Tier 5 Filgrastim Granix Limited to Kaiser Tenofovir alafenamide Vemlidy Limited to Kaiser Toremifene Fareston Limited to Kaiser Ferric citrate Auryxia Add QL of 360 tablets Tezacaftor/ivacaftor plus ivacaftor Symdeko Add QL of 60 tablets 10/01/ /13/2018 Metformin hcl ER 1,000 mg Fortamet 1,000 mg Add PA Lansoprazole ODT Prevacid SoluTab Add PA Febuxostat 40 mg Uloric 40 mg Add QL of 30 tablets Brigatinib 30 mg Alunbrig 30 mg Add QL of 60 tablets Hydrocodone w/ homatropine; belladonna alakaloids & opium; codeine sulfate; fentanyl; hydrocodone bitartrate; hydromorphone hcl; levorphanol tartrate; meperidine hcl; methadone hcl; morphine sulfate; morphine/naltrexone; oxycodone hcl; oxycodone hcl ER; oxymorphone hcl ER; oxymorphone hcl; tapentadol hcl; tramadol hcl; tramadol hcl ER; buprenorphine; butorphanol tartrate; pentazocine/naloxone; oxycodone/acetaminophen; oxycodone/aspirin; oxycodone/ibuprofen; acetaminophen/codeine; butalbital/acetaminophen/caffeine/codeine; butalbital/aspirin/caffeine/codeine; acetaminophen/caffeine/dihydrocodeine; aspirin/caffeine/dihydrocodeine; hydrocodone/acetaminophen; hydrocodone/ibuprofen; meperidine/promethazine; tramadol/acetaminophen; carisoprodol/aspirin/codeine High Dose Pain Medicine Prescriber Review: Members on high doses of certain pain medicines will need their prescriber to confirm safety standards are in place annually to continue coverage of therapy. Sofosbuvir Sovaldi Move to Tier 5 Ivacaftor 150 mg Kalydeco 150 mg Move to Tier 5 Praziquantel Biltricide Move to Tier 3
4 Ritonavir 100 mg Norvir 100 mg Move to Tier 3 Dihydroergotamine mesylate nasal spray Migranal Move to Tier 5 Testosterone cypionate IM Depo-Testosterone Move to Tier 3 Bexarotene Targretin Ancillary charge Pegvisomant Somavert Limited to Kaiser Guselkumab Tremfya Add QL of 1 syringe per 56 days Brodalumab Siliq Add QL of 2 syringes per 28 days Empagliflozin/metformin ER Synjardy XR Add QL of 30 tablets Codeine sulfate; hydromorphone; levorphanol; morphine sulfate; oxycodone IR; oxycodone/acetaminophen; oxycodone/aspirin; tramadol; tramadol/acetaminophen; buprenorphine sublingual; acetaminophen/codeine; hydrocodone/acetaminophen; hydrocodone/ibuprofen; meperidine; oxymorphone; tapentadol; oxycodone/ibuprofen; butalbital/acetaminophen/caffeine/codeine; butalbital/aspirin/caffeine/codeine; acetaminophen/caffeine/dihydrocodeine Endocet; Lorcet; Lorcet Plus; Lortab; Dilaudid; Demerol; Roxicodone; Opana; Nucynta; Ultram; Percocet; Primlev; Tylenol #3; Tylenol #4; Capital/codeine; Fioricet; Fiorinal; Panlor; Synalgos-DC; Trezix; Norco; Vicodin; Vicodin ES; Vicodin HP; Verdrocet; Xodol; Hycet; Zamicet; Ibudone; Reprexain; Vicoprofen; Xylon; Ultracet; Oxaydo Up short acting opioid QL for 7 days history of use. Maximum quantity now: 42 units or 210mLs for age >21 years; 18 units or 90mLs for age <21 years Atazanavir sulfate Sustiva Move to Tier 3 Efavirenz Reyataz capsules Move to Tier 5 Tenofovir disoproxil fumarate Viread Move to Tier 3 Codeine/chlorpheniramine Tuzistra XR Add PA Dapagliflozin/saxagliptin Qtern Add QL of 30 tablets
5 Doxylamine/pyridoxine Diclegis Add PA Diclofenac Cambia; Zorvolex Add PA Dextromethorphan/quinidine Nuedexta Add PA Icatibant acetate Firazyr Limited to Kaiser Immune globulin Hizentra Limited to Kaiser Fluticasone propionate Flonase Move to Tier 3, add PA Beclomethasone dipropionate Beconase AQ; Qnasl Add PA Ciclesonide Omnaris; Zetonna Add PA Budesonide Rhinocort Aqua Add PA Mometasone furoate Nasonex Add PA Promethazine/codeine Promethazine/phenylephrine/codeine Phenergan with codeine Phenergan VC with codeine Move to Tier 3; add PA Move to Tier 3; add PA Enoxaparin sodium Lovenox Ancillary charge Tofacitinib citrate ER Xeljanz XR Limited to Kaiser Prasugrel Effient Move to Tier 3 Moxifloxacin Vigamox Move to Tier 3 Fosamprenavir Lexiva Move to Tier 5 Abacavir Ziagen Move to Tier 3 Sevelamer Renvela Move to Tier 3 Estradiol Climara Move to Tier 3 01/01/ /13/2017
6 Enoxaparin Lovenox Move to Tier 3 Clidinium/chlordiazepoxide Librax Move to Tier 3 Scopolamine Transderm Scop Ancillary charge (generic available) Zileuton ER Zyflo CR Move to Tier 5 Becaplermin Regranex gel Move to Tier 5 Lurasidone Latuda Move to Tier 5 Dichlorphenamide Keveyis Move to Tier 5 Lanthanum carbonate Fosrenol Move to Tier 5 Felbamate Felbatol Move to Tier 5 Rufinamide Banzel Move to Tier 5 Alosetron Lotronex Move to Tier 5 Adefovir dipivoxil Hepsera Move brand to Tier 5; Move generic to Tier 4 Vancomycin Vancocin Move brand to Tier 5; Move generic to Tier 4 Erythromycin ethylsuccinate suspension Eryped; E.E.S. Move to Tier 3 Calcitriol Vectical ointment Move to Tier 2 Oxycodone Oxycontin CR Move to Tier 2 Mesalamine Asacol HD Move to Tier 2 Fluorouracil Carac cream Move to Tier 2 Colchicine Mitigare Move to Tier 2 Lenvatinib Lenvima Limited to Kaiser
7 Codeine sulfate; acetaminophen/codeine; promethazine/codeine; promethazine/phenylephrine/codeine; chlorpheniramine/codeine Tylenol with codeine; Phenergan with codeine; Lexuss; Tuzistra XR; Codar AR Cyclobenzaprine ER Amrix Add PA; add QL of 21 capsules per 180 days Methylpheni ER Cotempla Add QL of 30 tablets Amphetamine/dextroamphetamine Mydayis Add QL of 30 capsules per 30 days Fentanyl Actiq; Subsys; Abstral; Fentora; Lazanda Add PA Add QL of 4 dosing units per day Daclizumab Zinbryta Add QL of 1 syringe per 28 days Mometasone/formoterol Dulera Move to Tier 3 Ethacrynic acid Edecrin Add PA Ethacrynic acid Edecrin Move to Tier 3 01/01/ /11/2017
Future Formulary Changes
Future Formulary Changes Upd 11/21/2018 Applies to: Employer group plan 2018 2019 open formularies KEY: PA=prior authorization; ST=step therapy; QL=quantity limit Generic name Brand name Change Effective
More informationFuture Formulary Changes
Future Formulary Changes Upd 09/11/2018 Applies to: Employer group plan 2018 open formularies KEY: =prior authorization; ST=step therapy; QL=quantity limit Generic name Brand name Change Effective Hydroxyprogesterone
More informationFuture Formulary Changes
Future Formulary Changes Upd 05/16/2018 Applies to: Employer group plan 2018 open formularies with specialty tiers KEY: PA=prior authorization; ST=step therapy; QL=quantity limit Generic name Brand name
More informationCapital 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
More informationCigna Drug and Biologic Coverage Policy
Cigna Drug and Biologic Coverage Policy Subject Controlled Substance Analgesic and Narcotic Antagonist Quantity Limitations Table of Contents Coverage Policy... 1 General Background... 6 Coding/Billing
More informationOpioid Analgesic/Opioid Combination Products
Market DC Opioid Analgesic/Opioid Combination Products Override(s) Quantity Limit Approval Duration 1 year Generic Name Brand Name Quantity Limit APAP/Caf/Dihydrocodeine 320.5mg/30mg/16mg APAP/Caf/Dihydrocodeine
More informationMedical Policy An independent licensee of the Blue Cross Blue Shield Association
Opioid Immediate Release Page 1 of 13 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Opioid Immediate Release Prime Therapeutics will review Prior Authorization
More informationOpioid Analgesic/Opioid Combination Products
Opioid Analgesic/Opioid Combination Products Override(s) Quantity Limit Approval Duration 1 year Generic Name Brand Name Quantity Limit 320.5mg/30mg/16mg 356.4mg/30mg/16mg 325mg/30mg/16mg Trezix (new formulation)
More informationPRESCRIPTION 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
More informationPRESCRIPTION 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
More informationGeneric Label Name Drug Strength Dosage Form Example Product (s) MME/Unit ACETAMINOPHEN WITH CODEINE
STATE OF TENNESSEE DEPARTMENT OF FINANCE AND ADMINISTRATION DIVISION OF HEALTH CARE FINANCE AND ADMINISTRATION BUREAU OF TENNCARE 3 Great Circle Road NASHVILLE, TENNESSEE 37243 This notice is to advise
More informationPrior Authorization Opioid Overutilization 2017
Drugs Requiring Prior Authorization Label Name ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINE CAPSULE ACETAMINOPHEN/CODEINE SOLUTION ACETAMINOPHEN/CODEINE TABLET ASCOMP/CODEINE CAPSULE BUTALBITAL/CAFFEINE/ACETAMINOPHEN/CODEINE
More informationPRESCRIPTION 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
More informationAPPROVED PA CRITERIA. Initial Approval: January 10, 2018 Revised Dates: April 11, 2018 CRITERIA FOR PRIOR AUTHORIZATION
Initial Approval: January 10, 2018 Revised Dates: April 11, 2018 CRITERIA FOR PRIOR AUTHORIZATION PROVIDER GROUP Pharmacy Opioid Products Indicated for Pain Management MANUAL GUIDELINES All dosage forms
More informationCHANGES TO YOUR DRUG LIST
CHANGES TO YOUR DRUG LIST More generics and lower-cost brands to help you stay healthy and save money At Cigna, it s our goal to offer you access to coverage for safe, effective and affordable medications.
More informationXyrem (Sodium Oxybate)
Texas Prior Authorization Program Clinical Criteria Drug/Drug Class Clinical Criteria Information Included in this Document Drugs requiring prior authorization: the list of drugs requiring prior authorization
More informationADDITIONAL 2017 FORMULARY CHANGES CIGNA COMMERCIAL CUSTOMERS
ADDITIONAL 2017 FORMULARY CHANGES CIGNA COMMERCIAL CUSTOMERS Effective 7/1/2017, Cigna will be making additional formulary changes that may impact customers at your pharmacy. We have included a list of
More informationFORMULARY UPDATES TO DENVER HEALTH MEDICAID CHOICE (DHMC) AND CHILD HEALTH PLAN PLUS (CHP+) PLANS
FORMULARY UPDATES TO DENVER HEALTH MEDICAID CHOICE (DHMC) AND CHILD HEALTH PLAN PLUS (CHP+) PLANS DHMC/CHP+ may add or remove drugs from the formulary or make changes to restrictions on formulary drugs
More informationFORMULARY UPDATES TO DENVER HEALTH MEDICAID CHOICE (DHMC) AND CHILD HEALTH PLAN PLUS (CHP+) PLANS
FORMULARY UPDATES TO DENVER HEALTH MEDICAID CHOICE (DHMC) AND CHILD HEALTH PLAN PLUS (CHP+) PLANS DHMC/CHP+ may add or remove drugs from the formulary or make changes to restrictions on formulary drugs
More informationPharmacy Medical Necessity Guidelines: Opioid Analgesics
Pharmacy Medical Necessity Guidelines: Effective: January 1, 2019 Prior Authorization Required Type of Review Care Management Not Covered Type of Review Clinical Review Pharmacy (RX) or Medical (MED) Benefit
More informationADDITIONAL 2017 FORMULARY CHANGES CIGNA COMMERCIAL CUSTOMERS
ADDITIONAL 2017 FORMULARY CHANGES CIGNA COMMERCIAL CUSTOMERS Cigna will be making additional formulary changes that may impact customers at your pharmacy. We have included a list of drugs by drug class
More informationOpiate/Benzodiazepine/Muscle Relaxant Combinations
Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Opiate/Benzodiazepine/Muscle Relaxant Combinations Clinical Edit Information Included in this Document Drugs requiring prior authorization:
More informationTexas Prior Authorization Program Clinical Edit Criteria
Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Clinical Edit Information Included in this Document Drugs requiring prior authorization: the list of drugs requiring prior authorization
More informationPRESCRIPTION DRUG LIST CHANGES
PRESCRIPTION DRUG LIST CHANGES Cigna Pharmacy Management The medications listed below are changing coverage (or cost levels) on Cigna s Prescription Drug List. Changes are listed by drug list and by the
More informationOpioid Management Program October 2018
Opioid Management Program October 2018 What Is the Opioid Management Program? This program is based on guidelines developed by the U.S. Centers for Disease Control and Prevention (CDC). It consists of
More informationOpioid Management Program May 2018
Opioid Management Program May 2018 What Is the Opioid Management Program? This program is based on guidelines developed by the U.S. Centers for Disease Control and Prevention (CDC). It consists of daily
More informationCigna Drug and Biologic Coverage Policy
Cigna Drug and Biologic Coverage Policy Subject Opioid Therapy Table of Contents Coverage Policy... 1 General Background... 4 Coding/Billing Information... 7 References... 7 Effective Date..1/1/2018 Next
More information: Opioid Quantity Limits
March 7, 2017 2017-09: Opioid Quantity Limits The Louisiana Department of Health (LDH), in conjunction with the Louisiana Medicaid Drug Utilization Review (DUR) Board, has revised quantity limits for selected
More informationNew Hampshire Healthy Families CLINICAL POLICY
New Hampshire Healthy Families CLINICAL POLICY DEPARTMENT: Pharmacy DOCUMENT NAME: Opioid Analgesics PAGE: 1 o f 6 REFERENCE NUMBER: NH.PPA.13 EFFECTIVE DATE: 6/1/2016 REPLACES DOCUMENT: N/A RETIRED: REVIEWED:
More information** Fee-For-Service Pharmacy Provider Notice #229 May 2018 PDL Changes **
** Fee-For-Service Pharmacy Provider Notice #229 May 2018 PDL Changes ** August 03, 2018 Please be advised that the Department for Medicaid Services (DMS) is making changes to the Kentucky Medicaid Fee-For-Service
More information2017 Formulary Addendum Notice of Change (Medicare Advantage Plans)
207 Formulary Addendum Notice of Change (Medicare Advantage Plans) Easy Choice Health Plan Easy Choice Plus Plan (HMO) H5087-002, H5087-07 This is a listing of the changes that have occurred in our formulary.
More informationMedication Policy Manual. Topic: Immediate-release (IR) Opioid Medication Products for Pain. Date of Origin: January 1, 2018
Independent licensees of the Blue Cross and Blue Shield Association Medication Policy Manual Topic: Immediate-release (IR) Opioid Medication Products for Pain Policy No: dru516 Date of Origin: January
More informationDrug Name (specify drug) Quantity Frequency Strength
Prior Authorization Form GEHA FEDERAL - STANDARD OPTION 1363-M Opioids IR MME Limit and Post Limit This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,
More informationDrug Name (specify drug) Quantity Frequency Strength
Prior Authorization Form MEDICA HEALTH PLAN IA EXCHANGE 1362-M Opioids IR Labeling Post Limit (HMF) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,
More information2017 Formulary Addendum Notice of Change (Medicare Advantage Plans)
2017 Formulary Addendum Notice of Change (Medicare Advantage Plans) Easy Choice Health Plan Easy Choice Best Plan (HMO) H5087-005 This is a listing of the changes that have occurred in our formulary. Please
More informationFormulary Changes. One mission: you TABLE A. FORMULARY CHANGES 7/1/2018: Commercial 3-Tier Formulary. Commercial 4-Tier Formulary
One mission: you Changes July 1, 2018 Blue Cross of Idaho reviews its formularies (covered drug lists) periodically to allow members access to new drugs and to provide safe, cost effective options for
More informationHEALTH SHARE/PROVIDENCE (OHP)
HEALTH SHARE/PROVIDENCE (OHP) STEP THERAPY This is a complete list of drugs that have written coverage determination policies. Drugs on this list do not indicate that this particular drug will be covered
More informationPresbyterian Health Plan, Inc. Presbyterian Insurance Company, Inc. NOTIFICATION OF FORMULARY CHANGES
NOTIFICATION OF FORMULARY CHANGES The following summary describes changes to the Presbyterian Commercial Large Group Plans (Non-Metal Plans) Formularies effective 2018. For the most recent list of drugs,
More informationBeneficiary 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
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 information2018 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
More information10 mg hydrocodone equals how much oxycodone
Cari untuk: Cari Cari 10 mg hydrocodone equals how much oxycodone Posts about dilaudid 8 vs oxycodone 30 written by buyprescriptionmedication. Can you help me with the conversion of Oxycodone IR (5mg tab)
More informationDrug Formulary Update, January 2018 Commercial and State Programs
Drug Formulary Update, January 2018 Commercial and State Programs Updates to the HealthPartners Commercial and State Program Drug Formularies are listed below. Updates apply to all Commercial groups (PreferredRx,
More informationPeach State Health Plan routinely reviews the medications available on the Preferred Drug
Effective date: December 27, 2016 Peach State Health Plan Preferred Drug List (PDL) Updates Q4 2016 Peach State Health Plan routinely reviews the medications available on the Preferred Drug List (PDL).
More informationPresbyterian Health Plan, Inc. Presbyterian Insurance Company, Inc. NOTIFICATION OF FORMULARY CHANGES
NOTIFICATION OF FORMULARY CHANGES The following summary describes changes to the 2017 Presbyterian Individual and Family Metal Plan/Employer Group Metal Plan Formularies effective 2018. For the most recent
More information2017 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
More informationPharmacy 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
More informationRationale for Decision Excluded Generic OTC equivalent available (Flonase Allergy Relief) Medicare status (if differs)
BLUE SHIELD OF CALIFORNIA FIRST QUARTER 2015 FORMULARY AND MEDICATION POLICY UPDATES EFFECTIVE MARCH 19, 2015 The Blue Shield of California (BSC) Pharmacy and Therapeutics (P&T) Committee, consisting of
More informationBLUE SHIELD OF CALIFORNIA MARCH 2016 STANDARD DRUG FORMULARY CHANGES
BLUE SHIELD OF CALIFORNIA MARCH 2016 STANDARD DRUG FORMULARY CHANGES Blue Shield is committed to covering safe, effective and affordable medications, so we regularly review and update our drug formularies.
More informationPequot Health Care Opioid Analgesic Quantity Program*
Pequot Health Care 1 Annie George Drive Mashantucket, CT 06338 Phone: 1-888-779-6638 Fax: 1-860-396-6494 Pequot Health Care Opioid Analgesic Quantity Program* Effective January 2018 *Quantity Program limits
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 informationWellCare of South Carolina Preferred Drug List Update
WellCare of 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 August 21,
More informationBlueLink TPA FlexRx Updates
BlueLink TPA FlexRx Updates April 2018 TRADE NAME (generic name) or generic name abacavir sulfate soln 20 mg/ml (base equiv) Generic Addition, generic for ZIAGEN alclometasone dipropionate cream 0.05%
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 informationPrescription benefit updates Large group
Prescription benefit updates Large group Moda Health 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 information2018 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
More informationBlue 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
More informationSupplementary Online Content
Supplementary Online Content Lin DH, Jones CM, Compton WM, et al. Prescription drug coverage for treatment of low back pain among US Medicaid, Medicare Advantage, and commercial insurers. JAMA Netw Open.
More informationHigh-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
More informationDrug Name Description of Change Formulary Coverage Formulary Alternative(s)
NOTIFICATION OF FORMULARY CHANGES The following summary describes changes to the Presbyterian Centennial Care Formulary effective 2018. For the most recent list of drugs, information on asking for a prior
More informationMEDICARE Program Policies & Procedures POLICY NUMBER: Medicare D-111
POLICY: Medicare Part D Formulary-Level Cumulative Opioid and Opioid/Buprenorphine POS Edits MEDICARE Program Policies & Procedures POLICY NUMBER: Medicare D-111 Policy for contracts H3351, S3521 and H3335
More informationUpdates to your prescription benefits
Updates to your prescription benefits Effective July 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 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 informationICP Formulary Updates
ICP Formulary Updates July 2017 TRADE NAME (generic name) adapalene cream 0.1% 2017-07-01 Removal adapalene gel 0.3% 2017-07-01 Removal adefovir dipivoxil tab 10 mg 2017-07-01 Removal ADVAIR DISKUS (fluticasone-salmeterol
More informationUpdates to your prescription benefits
Updates to your prescription benefits Effective July 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 informationPharmacy and Therapeutics (P&T) Committee Provider Update
Pharmacy and Therapeutics (P&T) Committee Provider Update SECOND QUARTER 2018 P&T Committee Decisions Effective June 1, 2018 Dear Healthcare Practitioner: The Presbyterian Health Plan, Inc., and Presbyterian
More informationPRESCRIPTION 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
More informationChanges 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
More informationOpioid Capture in the AHSQC Can we reduce use by measuring it? Michael Reinhorn MD, MBA, FACS Dept of Surgery, Newton Wellesley Hospital
Opioid Capture in the AHSQC Can we reduce use by measuring it? Michael Reinhorn MD, MBA, FACS Dept of Surgery, Newton Wellesley Hospital Disclosure Davol/Bard Consultant Medtronic Physician Advisory Honorarium
More informationDrug Class Preferred Agents Non-Preferred Agents
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 of the Department for
More information1/1/2019 FORMULARY CHANGES CIGNA COMMERCIAL CUSTOMERS
1/1/2019 FORMULARY CHANGES CIGNA COMMERCIAL CUSTOMERS Effective 1/1/19, Cigna is making changes to our formularies that may impact medication coverage for customers at your pharmacy. We have included a
More informationSection 2 Class III, IV & V Pharmaceuticals Page 13
Section 2 Class III, IV & V Pharmaceuticals Page 13 ACETAMINOPHEN W/ CODEINE #3 30MG TABS (GENERIC TYLENOL) #100 41.99 ACETAMINOPHEN W/ CODEINE #3 30MG TABS #1000 298.99 ACETAMINOPHEN W/ CODEINE #4 60MG
More informationPRESCRIPTION DRUG BENEFITS. open/closed formulary. Capital BlueCross is an Independent Licensee of the BlueCross BlueShield Association
GUIDE TO PRESCRIPTION DRUG BENEFITS open/closed formulary Capital BlueCross is an Independent Licensee of the BlueCross BlueShield Association TABLE OF CONTENTS 2 Contact Us Phone Number Website 3 Using
More informationEmblem Medicaid 3Q18 Formulary Updates
ALKERAN 2 MG TABLET Removed from Formulary 7/9/2018 AMITIZA 24 MCG CAPSULES Removed from Formulary 7/9/2018 AMITIZA 8 MCG CAPSULE Removed from Formulary 7/9/2018 avo cream topical emulsion Removed from
More informationHigh-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
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 informationSTEP THERAPY CRITERIA
STEP THERAPY This is a complete list of drugs that have written coverage determination policies. Drugs on this list do not indicate that this particular drug will be covered under your medical or prescription
More informationJANUVIA 50 MG TABLET BYDUREON 2 MG/0.65 ML JARDIANCE 10 MG TABLET SUBCUTANEOUS PEN INJECTOR JARDIANCE 25 MG TABLET BYDUREON BCISE 2 MG/0.
ANTI DIABETICS BYDUREON 2 MG SUBCUTANEOUS JANUVIA 25 MG TABLET EXTENDED RELEASE SUSPENSION JANUVIA 50 MG TABLET BYDUREON 2 MG/0.65 ML JARDIANCE 10 MG TABLET SUBCUTANEOUS PEN INJECTOR JARDIANCE 25 MG TABLET
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 informationQuarterly pharmacy formulary change notice
Quarterly pharmacy formulary change notice Summary: The formulary changes listed in the table below were reviewed and approved at our fourth-quarter Pharmacy and Therapeutics Committee meeting. Provider
More informationMarch 2018 P & T Updates
March 2018 P & T Updates Commercial Triple Tier 4th Tier Applicable Traditional Prior Auth AURYXIA 3 2 12 tablets per BAXDELA TABLETS 3 2 2 tablets per Depending on your specific benefits and in which
More informationPrior Authorization Criteria AS OF July 1, 2018
Prior Authorization Criteria The following is the listing of SFHP prior authorization criteria that will be used to evaluate prior authorization requests. SFHP s pharmacy prior authorization criteria are
More informationMemorial Hermann Advantage HMO February 2019 Formulary Addendum
Memorial Hermann Advantage HMO February 2019 Formulary Addendum Changes may have occurred since the printing of your current Memorial Hermann Advantage HMO Formulary. Medications that may have been added
More informationAVMED 4 TIER AND 5 TIER FORMULARY QUANTITY LIMIT TABLE
Effective 4/1/2018 AVMED 4 TIER AND 5 TIER FORMULARY QUANTITY LIMIT TABLE Generic Name Brand Name Quantity Limit Description Comments ABACAVIR SOLN 20 MG/ML ZIAGEN 900ml every 30 days ABACAVIR TAB 300
More informationStep Therapy Medications
Step Therapy Medications Step Therapy Group APTIOM Step-2: APTIOM 200 MG TABLET or APTIOM 400 MG TABLET or APTIOM 600 MG TABLET or APTIOM 800 MG TABLET Step 1 Drug(s): Oxcarbazepine immediate-release,
More informationYour 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
More informationPrior Authorization for Opioid Products Indicated for Pain Management
Kansas Medical Assistance Program PA Phone 800-933-6593 PA Fax 800-913-2229 Amerigroup PA Pharmacy Phone 855-201-7170 PA Pharmacy Fax 800-601-4829 Sunflower PA Pharmacy Phone 877-397-9526 PA Pharmacy Fax
More information2018 Formulary Update
MEDICARE ADVANTAGE BlueShield of Northeastern New York 2018 Formulary Update BlueShield of Northeastern New York has updated its formulary (drug list) since its original publication in January 2018. This
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 information2014 FORMULARY LIST OF COVERED DRUGS
PLEASE READ: This formulary was updated on January 1, 2014. For more recent information or other questions, please contact Viva Medicare Member Services at 1-800-633-1542 or, for TTY users, 711, Monday
More informationSTEP THERAPY CRITERIA
STEP THERAPY This is a complete list of drugs that have written coverage determination policies. Drugs on this list do not indicate that this particular drug will be covered under your medical or prescription
More information2019 LIST OF COVERED DRUGS (FORMULARY)
2019 LIST OF COVERED DRUGS (FORMULARY) Prescription drug list information UnitedHealthcare Connected for MyCare Ohio (Medicare-Medicaid Plan) Toll-free 1-877-542-9236, TTY 711 8 a.m. - 8 p.m. local time,
More informationcomprehensive formulary (list of covered drugs) January 1st - December 31st leon cares medicare
comprehensive formulary (list of covered drugs) leon cares 2019 medicare January 1st - December 31st PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. Formulary ID
More informationStep Therapy Criteria
ADCIRCA 1772-D ADCIRCA Coverage will be provided if the member has filled a prescription for sildenafil (at least a 30 day supply within the past 365 AMYLIN ANALOG 676-D SYMLINPEN 120, SYMLINPEN 60 rapid-acting
More information15 mg morphine 10 mg hydrocodone
Cari untuk: Cari Cari 15 mg morphine 10 mg hydrocodone 3-2-2013 Convert From CALCULATED MORPHINE EQUIVALENT BY RESOURCE: Average ( mg ) Range ( mg ) Standard Deviation of Sample ( mg ) Hydrocodone. I usually
More information2018 OPEN FORMULARY Updates
January, 2018 01/01/2018 OPDIVO nivolumab 01/01/2018 KEVZARA sarilumab 01/01/2018 KEVZARA sarilumab 01/01/2018 AIMOVIG AUTOINJECTOR,AIMOVIG AUTOINJECTOR (2 PACK) erenumab-aooe 01/02/2018 glucose in water
More informationCommittee Approval Date: September 12, 2014 Next Review Date: September 2015
Medication Policy Manual Topic: fentanyl-containing medications: - Actiq, fentanyl citrate oral transmucosal lozenges - Abstral fentanyl sublingual tablets - Fentora, fentanyl buccal tablet - fentanyl
More information