Aetna Better Health of Illinois Medicaid Formulary Updates
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1 December 2016 Aetna Better Health f Illinis Medicaid 2016 Frmulary Updates Frmulary Additins Nilutamide tab 150MG Nitrglycerin SL (all strengths) Erythrmycin Ethylsuccinate Sus 200/5ML ABACAVIR SULFATE-LAMIVUDINE TAB MG-QL, (PA required as f 12/15/2016) Frmulary Remvals Nilandrn 150MG NitrStat SL (all strengths) ERYPED SUS 200/5ML E.E.S SUS 200/5ML Ergmar Epzicm Prir Authrizatin Required as f 12/15/2016 SELZENTRY FUZEON TIVICAY VITEKTA ISENTRESS REYATAZ PREZISTA LEXIVA CRIXIVAN VIRACEPT NORVIR INVIRASE APTIVUS ABACAVIR ZIAGEN VIDEX DIDANOSINE EMTRIVA LAMIVUDINE STAVUDINE ZIDOVUDINE VIREAD RESCRIPTOR SUSTIVA INTELENCE
2 Octber 2016 NEVIRAPINE NEVIRAPINE ER EDURANT DESCOVY TRUVADA LAMIVUDINE/ZIDOVUDINE KALETRA TRIUMEQ ABACAVIR SULFATE-LAMIVUDINE ATRIPLA COMPLERA GENVOYA STRIBILD Prir Authrizatin Required Chantix-PA September 2016 Frmulary Additins Algliptin(generic Nessina) -QL Algliptin/metfrmin(generic Kazan) -QL Algliptin/piglitazne(generic Oseni)-QL Anr Elipta-QL Ciprflxacin tic Descvy-QL First Vancmycin 25mg and 50mg cmpund kits Flnase (allergy and Children s Allergy) OTC - QL Genvya-QL Insect Repellants with QL f 1 bttle/30 days: OFF DEEP WDS AER 25% OFF Deep Wds AEROSOL EXTERNAL OFF Deep Wds Dry AEROSOL EXTERNAL OFF Deep Wds Sprtsmen AEROSOL 30 % EXTERNAL OFF Smth & Dry AEROSOL 15 % EXTERNAL OFF SMTH/DRY AER 15% ULTRATHON AER INSECT OFF Familycare Clean Feel LIQUID 5 % EXTERNAL Lansprazle (prescriptin strength) 15MG AND 30 MG-QL Pantprazle (NO LONGER REQUIRES STEP THERAPY) Omeprazle (prescriptin strength) 20mg and 40 mg-ql Rabeprazle-QL Rhincrt (allergy and Children s Allergy) OTC - QL Sawyer Insect Repellent LIQUID 20 % EXTERNAL-QL
3 Age Limits Carbamezapine ER 100mg-age limit, QL Prir Authrizatin Required Entrest-PA, QL Cabmetyx-PA, QL Mvantik-PA, QL Prevacid Slutabs-PA Rsuvastatin-PA, QL Tpical Teststerne with PA, QL TESTOSTERONE PAK 25MG/2.5GM TESTOSTERONE GEL 50MG TESTOSTERONE PAK 50MG/5GM TESTOSTERONE PUMP 1% 12.5MG TESTOST PUM GEL 2% 10MG Quantity Limits Added Only Buprpin tab 75mg Buprpin tab 100mg Buprpin tab SR 12hr 100mg Buprpin tab SR 24 hur 150mg Citalpram hydrbrmide ral sln 10mg/5ml Fluxetine cap 20mg Fluxetine sln 20mg/5ml Isentress Mirtazapine 30 mg Mirtazapine 45mg Mirtazapine dt 30mg Nasacrt (Children s)otc OTC Nasacrt Allergy Parxetine ral susp 10mg/5ml (base equiv) Sertraline tab 100mg Sertraline ral cnc 20mg/ml Stribild Tivicay Truvada Step Therapy Required Amitiza-ST Linzess-ST, QL Stilt-ST, QL Frmulary Remvals
4 Crestr (remve frm frmulary) August 2016 July 2016 June 2016 Age Limits Tramadl, PA required fr under 16 years ld Additins Levemir FlexTuch Pen Lantus Slstar Pen Methtrexate 25mg/ml Inj Remvals Azasan Bimatprst 0.03% Byetta Calcitril int Januvia Janumet Lumigan 0.01% Mincycline IR and ER tablets Nevanac Parxetine ER Relpax Sensipar Suprax 400mg cap Suprax 500mg suspensin Temazepam 7.5mg and 22.5mg Trexall Zvirax cream Olpatadine phthalmic sln Step Therapy additins Acyclvir intment, QLL Azpt Rzerem Tykerb Quantity Limits Entecavir, QLL Gabapentin,QLL=3,600 mg/day Lamivudine HBV tabs and slutin, QLL Viread, QLL Nexavar=120/30 days Aerchamber /Spacers QLL=2 per year
5 Add Tanzeum with ST Add AQUADEKS May 2016 April 2016 Additins Capecitabine with PA, QL Cefixime suspensin IV ibandrnate IV pamidrnate Mincycline ER capsules OTC Abreva, QLL Paricalcitrl added ST Revlimid with PA, QLL Sutent with PA, QLL Thalmid with PA, QLL Vtrient with PA, QLL Remve PA requirement frm Emend Remve Nrditrpin Remve Nutrpin March 2016 Add Acyclvir intment (generic Zvirax intment) Add Bactrban Nasal, PA Add Imatinib (generic Gleevec), PA Add Luprn, PA Add Naratriptan, QLL Add Neupgen, PA Add Olpatadine (generic Patanl) Add Rituxan, PA Add Rizatriptan ODT, QLL Add Rizatriptan, QLL Remve Gleevec Remve Patanl Remve Zvirax intment February 2016 Added Narcan Nasal Spray January 2016 As f January 1, 2016 Add Bunavail, QLL Add Zubslv, QLL Add Evzi
6 Add Vivitrl, QLL Add Acamprsate Add Epinastine with STEP Remve PA requirement fr Subxne Film Remve PA requirement fr buprenrphine/nalxne tab Remve PA requirement fr buprenrphine tab As f January 4, 2016 Remve PA requirement fr Amidarne Remve PA requirement fr leflunmide Remve PA requirement fr Rpinirle Remve PA requirement fr Pramipexle Remve PA requirement fr Selegiline Remve PA frm Ondansetrn tab/odt Tyzeka-all prescribers nw require PA Add Tradjenta with Step Add Jentaduet with Step Add Invkana with Step Add Invkamet with Step Add Farxiga with Step Add Trulicity with Step Add Invega Trinza with PA Add Hyalgan with PA Add Gel-One with PA Add Extavia with PA Add Glatpa with PA Add Aubagi with PA Add Omnitrpe Vials with PA Add Mdafanil with PA; QL #30/30 Add Tlterdine* IR with Step Add Tpical Tacrlimus with Step Add Fndaparinux with PA (21 Day supply available withut PA) Add Octretide with PA Add Tasgina with PA; QL #60/30 days Add Rectiv with PA; QL #30gm/30days Add Sandstatin LAR with PA Remve Betasern frm frmulary Remve Avnex frm frmulary
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