2014 Medicare Part D Formulary Formulary Additions

Transcription

1 Formulary Additions Used For Coverage Tier Bromday Ophthalmic Anti-inflammatory Invokana 100 mg Invokana 300 mg Namenda 14 mg ER Dementia Namenda 28 Titration Pack Dementia Namenda 21 mg ER Dementia Namenda 28 mg ER Dementia Namenda 7 mg ER Dementia Lorazepam Intensol 2 mg/ml Non-Preferred Lorazepam 1 mg tablet Non-Preferred Lorazepam 2 mg tablet Non-Preferred Lorazepam 0.5 mg tablet Non-Preferred

2 Formulary Deletions Glyburide Micronized 1.5 mg Glyburide 5 mg Glyburide 2.5 mg Glyburide Micronized 6 mg Glyburide 1.25 mg Glyburide Micronzied 3 mg 2.5 mg/500 mg 5 mg/500 mg 1.25 mg/250 mg Nifedipine 10 mg Nifedipine 20 mg Hydroxyzine 10 mg Used For Alternative Covered Alternative Covered Tier Glipizide/Metformin Non-Preferred Glipizide/Metformin Non-Preferred Glipizide/Metformin Non-Preferred Nifedipine ER Nifedipine ER Non-Preferred Non-Preferred, - - Non-Preferred

3 Formulary Deletions Used For Alternative Covered Alternative Covered Tier Hydroxyzine 25 mg, - - Non-Preferred Hydroxyzine 50 mg, - - Non-Preferred Hydroxyzine 100 mg, - - Non-Preferred Tekturna 150 mg Tekturna 300 mg 150 mg/12.5 mg 150 mg/25 mg 300 mg/12.5 mg 300 mg/25 mg Lisinopril, Losartan Lisinopril, Losartan Lisinopril - Preferred, Losartan - Non-Preferred Lisinopril - Preferred, Losartan - Non-Preferred - Non-Preferred - Non-Preferred - Non-Preferred - Non-Preferred

4 Negative Tier Changes Used For 2013 Coverage Tier 2014 Coverage Tier Metoclopramide 5 mg Gastroesophageal reflux Preferred Non-Preferred Metoclopramide 10 mg Gastroesophageal reflux Preferred Non-Preferred

5 Formulary Changes to Requirements or Limits Used For Requirements/Limits Changes Buprenorphine/naloxone 8 mg/2 mg SL Opioid dependence Addition of Prior Authorization Requirements Buprenorphine/naloxone 2 mg/0.5 mg SL Diclofenac/misoprostol 50 mg/200 mcg Diclofenac/misoprostol 75 mg/200 mcg Opioid dependence Arthritis Arthritis Addition of Prior Authorization Requirements Addition of Step Therapy Requirements Addition of Step Therapy Requirements Escitalopram 5 mg Depression Addition of Step Therapy Requirements Escitalopram 10 mg Depression Addition of Step Therapy Requirements Escitalopram 20 mg Depression Addition of Step Therapy Requirements Escitalopram 5 mg/5 ml Depression Addition of Step Therapy Requirements Lidoderm Patch Pain Removal of Prior Authorization Requirements Lunesta 1 mg Insomnia Removal of Step Therapy Requirements Lunesta 2 mg Insomnia Removal of Step Therapy Requirements Lunesta 3 mg Insomnia Removal of Step Therapy Requirements Montelukast 10 mg Asthma Addition of Step Therapy Requirements Montelukast 4 mg Chew Asthma Addition of Step Therapy Requirements Montelukast 5 mg Chew Asthma Addition of Step Therapy Requirements Montelukast 4 mg Pack Asthma Addition of Step Therapy Requirements Rozerem 8 mg Insomnia Addition of Prior Authorization Requirements Zaleplon 5 mg Insomnia Addition of Prior Authorization Requirements Zaleplon 10 mg Insomnia Addition of Prior Authorization Requirements Zolpidem 5 mg Insomnia Addition of Prior Authorization Requirements Zolpidem 10 mg Insomnia Addition of Prior Authorization Requirements Zolpidem ER 6.25 mg Insomnia Addition of Prior Authorization Requirements Zolpidem ER 12.5 mg Insomnia Addition of Prior Authorization Requirements