FORMULARY CHANGE NOTICE 2008 JULY
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1 FORMULARY CHANGE NOTICE 2008 JULY Drug Name Dosage Form Strength Alternative Medicine* Formulary Formulary Change and Reason Status of Alternative Medication Updated Status On Formulary STARLIX TABS 120MG Removal of Step Therapy T2 STARLIX TABS 60MG Removal of Step Therapy T2 ARCALYST SOLR 220 MG Addition T4 PA CIMZIA KIT 200 MG Addition T4 PA CORTENEMA ENEM 100 MG/60ML Addition T3 PA EVAMIST SOLN 1.53 MG/SPRAY Addition T3 PA FENOGLIDE TABS 120 MG Addition T3 PA FENOGLIDE TABS 40 MG Addition T3 PA FEXMID TABS 7.5 MG Addition T3 PA GRANISOL SOLN 2 MG/10ML Addition T1 IQUIX SOLN 1.5 % Addition T3 PA LIPOFEN CAPS 150 MG Addition T3 PA LIPOFEN CAPS 50 MG Addition T3 PA OMNARIS SUSP 50 MCG/ACT Addition T3 PA PATANASE SOLN 0.6 % Addition T3 PA PERFOROMIST NEBU 20 MCG/2ML Addition T3 PA SIMCOR TB MG,20 MG Addition T3 PA SIMCOR TB MG,20 MG Addition T3 PA SIMCOR TB MG,20 MG Addition T3 PA SORIATANE CK KIT 10 MG,0 -,0 - Addition T4 PA
2 Drug Name Dosage Form Strength Alternative Medicine* Formulary Status of Alternative Medication Formulary Change and Reason Updated Status On Formulary SORIATANE CK KIT 25 MG,0 -,0 - Addition T4 PA TREXIMET TABS 500 MG,85 MG Addition T3 PA ALIMTA SOLR 100 MG Addition T4 PA AVANDARYL TABS 2 MG,8 MG Addition T2 ST AVANDARYL TABS 4 MG,8 MG Addition T2 ST CALCIPOTRIENE SOLN % Addition T1 CIPROFLOXACIN I.V.-IN D5W SOLN 200 MG,5 % Addition T1 CIPROFLOXACIN I.V.-IN D5W SOLN 400 MG,5 % Addition T1 ERAXIS SOLR 100 MG Addition T4 PA ESTRADIOL/NORETHINDRONE A TABS 1 MG,0.5 MG Addition T1 FENTORA TABS 300 MCG Addition T3 PA FLUOROURACIL CREA 5 % Addition T1 LAMISIL PACK 125 MG Addition T3 PA LAMISIL PACK MG Addition T3 PA MAGNACET TABS 400 MG,10 MG Addition T3 PA MAGNACET TABS 400 MG,2.5 MG Addition T3 PA MAGNACET TABS 400 MG,5 MG Addition T3 PA MAGNACET TABS 400 MG,7.5 MG Addition T3 PA MONODOX CAPS 75 MG Addition T3 PA NUTROPIN AQ PEN SOLN 20 MG/2ML Addition T4 PA OPANA ER TB12 15 MG Addition T3 PA OPANA ER TB12 30 MG Addition T3 PA
3 Drug Name Dosage Form Strength Alternative Medicine* Formulary Status of Alternative Medication Formulary Change and Reason Updated Status On Formulary OPANA ER TB MG Addition T3 PA OXYCONTIN TB12 15 MG Addition T3 PA OXYCONTIN TB12 30 MG Addition T3 PA OXYCONTIN TB12 60 MG Addition T3 PA PLAVIX TABS 300 MG Addition T2 PROSOL SOLN 2.76 GM/100ML,1.96 GM/100ML,600 MG/100ML,1.02 Addition T3 PA PROTONIX PACK 40 MG Addition T2 ST PULMICORT SUSP 1 MG/2ML Addition (AL= max 8 years old) T2 AL RAMIPRIL CAPS 1.25 MG Addition T1 SULAR TB24 17 MG Addition T2 SULAR TB MG Addition T2 SULAR TB24 34 MG Addition T2 SULAR TB MG Addition T2 VOLTAREN GEL 1 % Addition T3 PA XYZAL SOLN 2.5 MG/5ML Addition T3 ST ACTONEL TABS 150 MG Addition T2 AMITIZA CAPS 8 MCG Addition T2 ACARBOSE TABS 100 MG Addition T1 ST ACARBOSE TABS 25 MG Addition T1 ST ACARBOSE TABS 50 MG Addition T1 ST PAROXETINE HCL ER TB MG Addition T1 PAROXETINE HCL ER TB24 25 MG Addition T1
4 Drug Name Dosage Form Strength Alternative Medicine* Formulary Status of Alternative Medication Formulary Change and Reason Updated Status On Formulary ROPINIROLE HCL TABS 0.25 MG Addition T1 ROPINIROLE HCL TABS 0.5 MG Addition T1 ROPINIROLE HCL TABS 1 MG Addition T1 ROPINIROLE HCL TABS 2 MG Addition T1 ROPINIROLE HCL TABS 3 MG Addition T1 ROPINIROLE HCL TABS 4 MG Addition T1 ROPINIROLE HCL TABS 5 MG Addition T1 Key T1 = Tier One Cost Share T2 = Tier Two Cost Share T3 = Tier Three Cost Share T4 = Tier Four Cost Share AL= Age Limit PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limits Addition = Drug Was Added To Formulary Deletion= Drug Was Removed From Formulary Drug Name= Name of the affected Part D drug Alternative Medicine= Drugs in the same therapeutic category, class or cost-sharing tier Formulary Status of Alternative Medication= The expected cost-sharing for alternative medicine Formulary Change and Reason= Description of the formulary change and reason if the covered part D drug is being removed from the formulary *Alternative drugs listed here are only suggestions. Only your physician can determine if the alternative listed here is appropriate for you. Please consult to your physicain as to whether this is an apropriate drug for you.
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