2018 Drug List Change Notice Updated 10/25/2018
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- Lewis Jasper Sanders
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1 2018 Drug List Change Notice Updated 10/25/2018 If you are taking a drug that is removed from the drug list, we will tell you. We will also tell you if we add any restrictions on a drug such as: Quantity limits Prior authorization Step therapy Move a drug to a higher [cost sharing] tier We will tell you at least 60 days before we make these changes. This gives you time to talk to your doctor about what to do next. Sometimes the Food and Drug Administration (FDA) finds that drugs are not safe. If the FDA says a drug you are taking is not safe, we will take it off the drug list right away. We will also send you a letter telling you that. The table below shows changes made to our drug list. Date of Change Drug Name Type of Change Possible Alternative 1/1/2018 benzoyl peroxide BPO MY WASH KIT EX COMPLETEPACK KIT 1/1/2018 BODI PROTECT OINT skin protectants, misc. OINT 1/1/2018 CERALYTE 70 SOLN 60MEQ/L- 70MEQ/L- 20MEQ/L- 30MEQ/L oral electrolytes SOLN H0022_18_FormularyNoticeWeb_Approved_
2 1/1/2018 COLYTE- FLAVOR PACKS SOLR 227.1GM- 21.5GM- 5.53GM- 2.82GM- 6.36GM 1/1/2018 EGRIFTA SOLR 2 MG 1/1/2018 MENHIBRIX SOLR 1/1/2018 METHYLPHEN IDATE HCL ER TBCR 18 MG 1/1/2018 molindone hcl 5mg tabs 1/1/2018 POCKETPEAK PEAK FLOW METER/UNIVE RSAL RANGE DEVI 1/1/2018 PRENAISSANC E BALANCE CAPS 1/1/2018 PROSHIELD PROTECTIVE HANDM METHYLPHENIDATE HCL ER POCKETPEAK PEAK FLOW METER/UNIVERSAL RANGE LPM Removed non-medicaid and non-part D skin protectants, misc.
3 1/1/2018 RASUVO SOAJ RASUVO SOAJ MG/0.15ML, 10 MG/0.55ML MG/0.2ML, 12.5 MG/0.25ML, 15 MG/0.3ML, 17.5 MG/0.35ML, 22.5 MG/0.45ML, 25 MG/0.5ML and 30 MG/0.6ML 1/1/2018 ticlopidine hcl 1/1/2018 TREANDA SOLN 180 MG/2ML, 45 MG/0.5ML TREANDA SOLR 1/1/2018 VIIBRYD KIT 1/1/2018 VP-CH-PNV CAPS Removed non-medicaid and non-part D 2/1/2018 AVEENO POSITIVELY AGELESS LIFT & FIRM EYE 2/1/2018 AVEENO POSITIVELY AGELESS NIGHT 2/1/2018 INTRON A W/DILUENT SOLR 2/1/2018 LOCORT 11- DAY TBPK 2/1/2018 LOCORT 7- DAY TBPK 2/1/2018 NEWGEN Removed non-part D eligible drug (not on NSDE) INTRON A SOLR NES
4 2/1/2018 OTREXUP SOAJ 7.5 MG/0.4ML 2/1/2018 PEAK FLOW METER DEVI POCKETPEAK PEAK FLOW METER/UNIVERSAL RANGE LPM 2/1/2018 REZIRA 2/1/2018 ROC MULTI CORREXION LIFTANTI- GRAVITY NIGHT 2/1/2018 ZONACORT 11 DAY TBPK 2/1/2018 ZONACORT 7 DAY TBPK 3/1/2018 calcium & RISACAL-D phosphorus w/ vitamin d 3/1/2018 PERFECT IRON 4/1/2018 DIABETA 1.25 MG glyburide tabs or 1.25 mg 4/1/2018 DIABETA 2.5 MG glyburide tabs or 2.5 mg 4/1/2018 DIABETA 5 MG glyburide tabs or 5 mg 4/1/2018 didanosine CPDR 125 MG 4/1/2018 DILAUDID SOLN IJ 2 MG/ML 4/1/2018 FERGON ferrous gluconate tabs or 240 mg
5 4/1/2018 molindone hcl 10mg tabs 4/1/2018 molindone hcl 25mg tabs 4/1/2018 PROMETHAZI Removed non-part D eligible drug (not promethazine & NE/PHENYLEP on NSDE) phenylephrine syrp HRINE 4/1/2018 TYZEKA 5/1/2018 5/1/2018 5/1/2018 5/1/2018 CARB-O-LAN 10 CARB-O-LAN 20 CARB-O- PHILIC/20 CARB-O-SAL 5 DML FORTE, CERAVE, SORBOLENE, VELVACHOL DML FORTE, CERAVE, SORBOLENE, VELVACHOL DML FORTE, CERAVE, SORBOLENE, VELVACHOL DML FORTE, CERAVE, SORBOLENE, VELVACHOL 5/1/2018 GEMCITABINE Removed non-part D eligible drug (not HYDROCHLOR on NSDE) IDE SOLN 2 GM/20ML 5/1/2018 NEVIRAPINE SUSP 50 MG/5ML 5/1/2018 TIMOPTIC-XE SOLG 0.5% 6/1/2018 IMOGAM RABIES-HT SOLN VIRAMUNE SUSP 50 MG/5ML Removed non-part D eligible drug (not on NSDE) HYPERRAB S/D SOLN
6 6/1/2018 PREDNISOLON Removed non-part D eligible drug (not E ACETATE P- F on NSDE) 6/1/2018 BRINTELLIX TRINTELLIX 5 5 MG MG 6/1/2018 BRINTELLIX TRINTELLIX MG MG 6/1/2018 BRINTELLIX TRINTELLIX MG MG 6/1/2018 desmopressin DDAVP SOLN NA 0.01 acetate % refrigerated SOLN 6/1/2018 lindane LOTN 6/1/2018 PROFE FORTE EZFE FORTE 6/1/2018 TG 10PEH/380GFN phenylephrineguaifenesin tabs 380mg-10mg 7/1/2018 acetic acidaluminum acetate soln 7/1/2018 oxycodone w/ acetaminophen soln 5mg/5ml- 325mg/5ml 7/1/2018 NITROMIST AERS 7/1/2018 methotrexate Sodium Inj PF 100 MG/4ML 7/1/2018 methotrexate Sodium Inj PF 200 MG/8ML NITROGLYCERIN LINGUAL AERS
7 7/1/2018 PRENATAL FORMULA 30UNIT- 200MG- 4000UNIT- 25MG-1.8MG- 28MG-20MG- 1.7MG-8MCG- 800MCG- 2.6MG-120MG- 400UNIT 7/1/2018 ACIDOPHILUS ACIDOPHILUS/CITRU PLUS PECTIN S PECTIN, KALA 7/1/2018 calcium carbonate-mag hydrox CHEW 300MG-700MG 7/1/2018 HAIR/SKIN/NA ILS 25MG-10MG- 170MG-5UNIT- 150MCG- 25MG-1.8MG- 20MG-16MG- 200MG-6MCG- 400MCG- 300MCG 7/1/2018 MEGA MULTI MEN TBCR MI-ACID CHEW CENTRUM CARDIO, CENTRUM ULTRA WOMENS ENDUR-VM TBCR, ENDUR-VM WITH IRON TBCR, ULTRA MEGA TWO TBCR
8 7/1/2018 ENDUR-VM TBCR, ENDUR-VM WITH MEGA MULTI IRON WOMEN TBCR TBCR, ULTRA MEGA TWO TBCR 7/1/2018 MINERAL OIL mineral oil oil or 100 % OIL OR 55 % 7/1/2018 DAILY MULTIPLE 7/1/2018 EQL MEGA SELECT WOMENS VITAMIN PLUS IRON 7/1/2018 EQL MEGA SELECT MENS 7/1/2018 EQL ONE DAILY DIET SUPPORT 7/1/2018 EQL ONE DAILY MENS 50+ ADVANCED 7/1/2018 MULTIVITAL PLATINUM 7/1/2018 PRO-CLEAR AC SYRP 7/1/2018 pseudoephedrine -guaifenesin 400MG- 60MG Multiple Vitamins w/ Iron Tab Multiple Vitamins w/ Minerals Tab Multiple Vitamins w/ Minerals Tab Multiple Vitamins w/ Minerals Tab Multiple Vitamins w/ Minerals Tab Multiple Vitamins w/ Minerals Tab AMBI 60PSE/400GFN
9 7/1/2018 phenylephrineguaifenesiguaifenesin phenylephrine- LIQD LIQD 100MG/5ML- 100MG/5ML- 2.5MG/5ML 5MG/5ML 7/1/2018 EQL PROTECTAVIS ION CAPS 7/1/2018 EQL SUPER ENERGY BOOSTER PACK 7/1/2018 EQL OMEGA 3 FISH OIL TRIPLE STRENGTH CAPS 7/1/2018 chlorpheniramin e-phenylephrineacetaminophen TBEF 7/1/2018 pediatric multiple vitamin w/ minerals & c CHEW 6.25MG- 6.25MG-5MG- 1667UNIT- 10UNIT-40MG FISH OIL TRIPLE STRENGTH CAPS GNP COLD RELIEF PLUS TBEF pediatric multiple vitamin w/ minerals & c CHEW 183UNIT- 500MCG-1.33MG- 6MG-0.6MCG- 150MCG-6MCG- 1.1MG-45MG, 15UNIT- 1.05MG-1998UNIT- 10MG-1.2MG-4.5MCG- 400UNIT-300MCG- 1.05MG-60MG, 1.3MG- 15MCG-2.5MG- 1000UNIT-1.5MCG- 300UNIT-100MCG- 9UNIT-38MCG-0.5MG- 15MG, 1.3MG-9U
10 8/1/2018 acyclovir sodium solr 500 mg 8/1/2018 GILENYA CAP (CMs 0.25MG excluded clinic pack) 8/1/2018 PREMESISRX Removed non-medicaid and non-part D PRENATE AM 8/1/2018 ZODEX 6-DAY TBPK 8/1/2018 AQUADERM RESTA 8/1/2018 chlorpheniramin COLD RELIEF PLUS e-phenylephrineacetaminophen TBEF 8/1/2018 EQL MEGA MULTIVITAMIN SELECT MENS ADULTS 8/1/2018 EQL MEGA SELECT WOMENS 8/1/2018 EQL ONE DAILY DIET SUPPORT 8/1/2018 EQL ONE DAILY MENS 50+ ADVANCED 8/1/2018 EQL OMEGA 3 FISH OIL TRIPLE STRENGTH CAPS MULTIVITAMIN ADULTS MULTIVITAMIN ADULTS MULTIVITAMIN ADULTS FISH OIL ULTRA
11 8/1/2018 EQL REPLACE PROTECTAVIS ION CAPS 8/1/2018 EQL SUPER EMERGEN-C ENERGY IMMUNE BOOSTER PACK 8/1/2018 LANTISEPTIC HYDRO-LAN THERAPEUTIC M 9/1/2018 BENDAMUSTI (CMS BENDEKA SOLN NE excluded labeler code) HYDROCHLOR IDE SOLN 9/1/2018 ELTA CERAVE, VELVACHOL, CERAVE RENEWING SA 9/1/2018 KEYTRUDA SOLR 9/1/2018 NUEDEXTA Added prior authorization for new starts 9/1/2018 RESCON DM SYRP 9/1/2018 RESCON-GG ED BRON GP LIQD 9/1/2018 THERANATAL THERANATAL LACTATION LACTATION SUPPORT COMPLETE MISC 9/1/2018 VENLAFAXIN venlafaxine hcl er E HCL ER 10/1/2018 ONDANSETRO (not N on NSDE) HYDROCHLOR IDE SOLN ondansetron hcl
12 10/1/2018 ROBITUSSIN ROBITUSSIN PEAK DM SYRP COLD DM SYRP 10/1/2018 GLEOSTINE CAPS 5 MG 10/1/2018 POTIGA 300 MG 10/1/2018 SODIUM CHLORIDE SOLN IV 0.9 % 10/1/2018 ISTODAX SOLR 10/1/2018 PEG-INTRON REDIPEN PAK 4 KIT 10/1/2018 diphenhydramine hcl SYRP OR 12.5 MG/5ML (Unapproved drug other) sodium chloride soln iv 0.9% 11/1/2018 ORBACTIV 11/1/2018 FORTICAL calcitonin (salmon) soln SOLN 11/1/2018 ALEVAMAX Removed non-medicaid and non-part D 11/1/2018 Removed non-medicaid and non-part D NUTRASEB 11/1/2018 Pyrilamine- Phenylephrine Tab MG 11/1/2018 VP DERMABASE Removed non-medicaid and non-part D 11/1/2018 REMIGEN M Removed non-medicaid and non-part D 11/1/2018 GNP VITAMIN D- Removed non-medicaid and non-part D /1/2018 PELEVERUS CLEAR OINT
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