UPHP Advantage (HMO) (H ) and UPHP Choice (HMO) (H ) Updates
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- Marion Todd
- 5 years ago
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1 March, /01/2018 clindacin p clindamycin phosphate 03/01/2018 glatiramer acetate 03/01/2018 glatiramer acetate 03/01/2018 oseltamivir phosphate 03/01/2018 oseltamivir phosphate 03/01/2018 ADACEL TDAP diphtheria,pertussis(acellular ),tetanus vaccine/pf 03/01/2018 levonorg-eth estrad eth estrad 03/01/2018 levonorg-eth estrad eth estrad glatiramer acetate ADD UM: QUANTITY 30 / 30 DAYS glatiramer acetate Specialty oseltamivir phosphate oseltamivir phosphate ADD UM: QUANTITY 720 / 365 OVER levonorgestrel/ethinyl and ethinyl levonorgestrel/ethinyl and ethinyl ADD UM: QUANTITY Preferred 91 / 91 DAYS 03/01/2018 PROLENSA bromfenac sodium Non-Preferred 03/01/2018 PROLENSA bromfenac sodium ADD UM: QUANTITY 12 / 365 OVER 03/01/2018 NYMALIZE nimodipine Specialty 03/01/2018 paroxetine mesylate 03/01/2018 paroxetine mesylate paroxetine mesylate ADD UM: QUANTITY 30 / 30 DAYS paroxetine mesylate Non-Preferred 03/01/2018 morphine sulfate morphine sulfate PAGE 1 UPDATED 09/2018
2 03/01/2018 glatiramer acetate 03/01/2018 glatiramer acetate glatiramer acetate ADD UM: QUANTITY 12 / 28 DAYS glatiramer acetate Specialty 03/01/2018 ZENPEP lipase/protease/amylase Preferred 03/01/2018 testosterone testosterone Non-Preferred 03/01/2018 GLYXAMBI empagliflozin/linagliptin Preferred 03/01/2018 GLYXAMBI empagliflozin/linagliptin ADD UM: QUANTITY 30 / 30 DAYS 03/01/2018 GLYXAMBI empagliflozin/linagliptin Preferred 03/01/2018 GLYXAMBI empagliflozin/linagliptin ADD UM: QUANTITY 30 / 30 DAYS 03/01/2018 doxycycline hyclate 03/01/2018 doxycycline hyclate doxycycline hyclate doxycycline hyclate 03/01/2018 methotrexate methotrexate sodium 03/01/2018 OPDIVO nivolumab Specialty 03/01/2018 HAVRIX hepatitis a virus vaccine/pf Preferred 03/01/2018 KADCYLA ado-trastuzumab emtansine Specialty 03/01/2018 VAQTA hepatitis a virus vaccine/pf Preferred 03/01/2018 VAQTA hepatitis a virus vaccine/pf Preferred 03/01/2018 piperacillintazobactam piperacillin sodium/tazobactam sodium 03/01/2018 XURIDEN uridine triacetate ADD UM: QUANTITY 120 / 30 DAYS 03/01/2018 XURIDEN uridine triacetate Specialty 03/01/2018 haloperidol decanoate haloperidol decanoate PAGE 2 UPDATED 09/2018
3 03/01/2018 meropenem meropenem 03/01/2018 oxaliplatin oxaliplatin 03/01/2018 XIIDRA lifitegrast ADD UM: QUANTITY 60 / 30 DAYS 03/01/2018 XIIDRA lifitegrast Non-Preferred 03/01/2018 TREANDA bendamustine hcl Specialty 03/01/2018 methylphenidate la 03/01/2018 methylphenidate la 03/01/2018 methylphenidate er methylphenidate hcl Non-Preferred methylphenidate hcl ADD UM: QUANTITY 30 / 30 DAYS methylphenidate hcl CHANGE UM: QUANTITY 30 / 30 days 30 / 30 DAYS 03/01/2018 RAYALDEE calcifediol Specialty 03/01/2018 NOVAREL chorionic gonadotropin, human Non-Preferred 03/01/2018 isibloom desogestrel-ethinyl 03/01/2018 klor-con potassium chloride 03/01/2018 XATMEP methotrexate Non-Preferred 03/01/2018 RADICAVA edaravone Specialty 03/01/2018 HUMALOG JUNIOR KWIKPEN insulin lispro Preferred 03/01/2018 RENFLEXIS infliximab-abda Specialty 03/01/2018 BAXDELA delafloxacin meglumine Specialty 03/01/2018 BAXDELA delafloxacin meglumine Specialty 03/01/2018 TREMFYA guselkumab Specialty 03/01/2018 SYNDROS dronabinol ADD UM: QUANTITY 120 / 30 DAYS PAGE 3 UPDATED 09/2018
4 03/01/2018 SYNDROS dronabinol Specialty 03/01/2018 BENLYSTA belimumab Specialty 03/01/2018 VOSEVI sofosbuvir/velpatasvir/voxila previr 03/01/2018 VOSEVI sofosbuvir/velpatasvir/voxila previr ADD UM: QUANTITY 84 / 365 OVER Specialty 03/01/2018 BENLYSTA belimumab Specialty 03/01/2018 IDHIFA enasidenib mesylate Specialty 03/01/2018 IDHIFA enasidenib mesylate ADD UM: QUANTITY 30 / 30 DAYS 03/01/2018 IDHIFA enasidenib mesylate ADD UM: QUANTITY 30 / 30 DAYS 03/01/2018 IDHIFA enasidenib mesylate Specialty 03/01/2018 NERLYNX neratinib maleate ADD UM: QUANTITY 180 / 30 DAYS 03/01/2018 NERLYNX neratinib maleate Specialty 03/01/2018 MAVYRET glecaprevir/pibrentasvir ADD UM: QUANTITY 336 / 365 OVER 03/01/2018 MAVYRET glecaprevir/pibrentasvir Specialty 03/01/2018 LYNPARZA olaparib Specialty 03/01/2018 LYNPARZA olaparib Specialty 03/01/2018 VYXEOS daunorubicin/cytarabine liposomal Specialty 03/01/2018 GOCOVRI amantadine hcl Specialty 03/01/2018 GOCOVRI amantadine hcl Specialty 03/01/2018 MYLOTARG gemtuzumab ozogamicin Specialty 03/01/2018 ALIQOPA copanlisib di-hcl Specialty 03/01/2018 profeno fenoprofen calcium Non-Preferred PAGE 4 UPDATED 09/2018
5 03/01/2018 LUPRON DEPOT-PED leuprolide acetate CHANGE UM: QUANTITY 1 / 112 days 1 / 84 OVER 03/01/2018 VABOMERE meropenem/vaborbactam Specialty 03/01/2018 VERZENIO abemaciclib Specialty 03/01/2018 VERZENIO abemaciclib ADD UM: QUANTITY 60 / 30 DAYS 03/01/2018 VERZENIO abemaciclib Specialty 03/01/2018 VERZENIO abemaciclib ADD UM: QUANTITY 60 / 30 DAYS 03/01/2018 VERZENIO abemaciclib ADD UM: QUANTITY 60 / 30 DAYS 03/01/2018 VERZENIO abemaciclib Specialty 03/01/2018 VERZENIO abemaciclib ADD UM: QUANTITY 60 / 30 DAYS 03/01/2018 VERZENIO abemaciclib Specialty 03/01/2018 INGREZZA valbenazine tosylate Specialty 03/01/2018 INGREZZA valbenazine tosylate ADD UM: QUANTITY 30 / 30 DAYS 03/01/2018 CALQUENCE acalabrutinib ADD UM: QUANTITY 60 / 30 DAYS 03/01/2018 CALQUENCE acalabrutinib Specialty 03/01/2018 BOSULIF bosutinib Specialty 03/01/2018 PREVYMIS letermovir Specialty 03/01/2018 PREVYMIS letermovir Specialty 03/01/2018 PREVYMIS letermovir Specialty 03/01/2018 PREVYMIS letermovir Specialty 03/01/2018 FASENRA benralizumab Specialty 03/01/2018 JULUCA dolutegravir sodium/rilpivirine hcl 03/01/2018 JULUCA dolutegravir sodium/rilpivirine hcl ADD UM: QUANTITY 30 / 30 DAYS Specialty PAGE 5 UPDATED 09/2018
6 03/01/2018 BYDUREON BCISE 03/01/2018 BYDUREON BCISE exenatide microspheres ADD UM: QUANTITY 3.4 / 28 DAYS exenatide microspheres Non-Preferred 03/01/2018 timolol maleate timolol maleate Non-Preferred 03/01/2018 TRISENOX arsenic trioxide Specialty 03/01/2018 potassium chloride potassium chloride 03/01/2018 efavirenz efavirenz 03/01/2018 scopolamine scopolamine 03/01/2018 dactinomycin dactinomycin Specialty 03/01/2018 vigabatrin vigabatrin Specialty 03/01/2018 TAMIFLU oseltamivir phosphate Non-Preferred 03/01/2018 TAMIFLU oseltamivir phosphate ADD UM: QUANTITY 110 / 365 OVER 03/01/2018 eletriptan hbr eletriptan hydrobromide ADD UM: QUANTITY 12 / 30 OVER 03/01/2018 eletriptan hbr eletriptan hydrobromide Non-Preferred 03/01/2018 eletriptan hbr eletriptan hydrobromide Non-Preferred 03/01/2018 eletriptan hbr eletriptan hydrobromide ADD UM: QUANTITY 12 / 30 OVER 03/01/2018 fosamprenavir calcium fosamprenavir calcium Specialty 03/01/2018 bortezomib bortezomib Specialty 03/01/2018 moxifloxacin moxifloxacin hcl PAGE 6 UPDATED 09/2018
7 03/01/2018 amnesteem isotretinoin Non-Preferred 03/01/2018 amnesteem isotretinoin Non-Preferred 03/01/2018 amnesteem isotretinoin Non-Preferred 03/01/2018 lanthanum carbonate lanthanum carbonate Specialty 03/01/2018 aripiprazole aripiprazole ADD UM: QUANTITY 750 / 30 DAYS 03/01/2018 aripiprazole aripiprazole Non-Preferred 03/01/2018 lanthanum carbonate lanthanum carbonate Specialty 03/01/2018 NEVANAC nepafenac ADD UM: QUANTITY 6 / 30 OVER 03/01/2018 NEVANAC nepafenac Preferred 03/01/2018 dapsone dapsone Non-Preferred 03/01/2018 lanthanum carbonate lanthanum carbonate Specialty 03/01/2018 mesalamine mesalamine Preferred 03/01/2018 TAMIFLU oseltamivir phosphate Non-Preferred 03/01/2018 TAMIFLU oseltamivir phosphate ADD UM: QUANTITY 112 / 365 OVER 03/01/2018 TAMIFLU oseltamivir phosphate Non-Preferred 03/01/2018 TAMIFLU oseltamivir phosphate ADD UM: QUANTITY 60 / 365 OVER PAGE 7 UPDATED 09/2018
8 03/01/2018 ethynodiol-ethinyl 03/01/2018 sevelamer carbonate 03/01/2018 desogestrelethinyl 03/01/2018 norgestimateethinyl ethynodiol diacetate-ethinyl sevelamer carbonate Preferred desogestrel-ethinyl norgestimate-ethinyl 03/01/2018 HAVRIX hepatitis a virus vaccine/pf Preferred 03/01/2018 TWINRIX hepatitis a virus and hepatitis b virus vaccine/pf 03/01/2018 caspofungin acetate 03/01/2018 caspofungin acetate 03/01/2018 adapalenebenzoyl peroxide Preferred caspofungin acetate Specialty caspofungin acetate Specialty adapalene/benzoyl peroxide Non-Preferred 03/01/2018 prasugrel hcl prasugrel hcl Non-Preferred 03/01/2018 prasugrel hcl prasugrel hcl Non-Preferred 03/01/2018 VENTOLIN HFA albuterol sulfate Non-Preferred 03/01/2018 VENTOLIN HFA albuterol sulfate ADD UM: QUANTITY 48 / 30 DAYS 03/01/2018 carvedilol er carvedilol phosphate Preferred 03/01/2018 Non-Preferred 03/01/2018 peg electrolyte peg 3350/sod sulf/sod bicarb/sod chloride/potassium chloride PAGE 8 UPDATED 09/2018
9 03/01/2018 FYCOMPA perampanel CHANGE TIER Specialty Non-Preferred 03/01/2018 FYCOMPA perampanel CHANGE TIER Specialty Non-Preferred 03/01/2018 FYCOMPA perampanel CHANGE TIER Specialty Non-Preferred 03/01/2018 FYCOMPA perampanel CHANGE TIER Specialty Non-Preferred 03/01/2018 SUPRAX cefixime CHANGE TIER Specialty Preferred 03/01/2018 ENTRESTO sacubitril/valsartan CHANGE TIER Non-Preferred Preferred 03/01/2018 ENTRESTO sacubitril/valsartan CHANGE UM: QUANTITY 60 / 30 days 60 / 30 DAYS 03/01/2018 ENTRESTO sacubitril/valsartan CHANGE TIER Non-Preferred Preferred 03/01/2018 ENTRESTO sacubitril/valsartan CHANGE UM: QUANTITY 60 / 30 days 60 / 30 DAYS 03/01/2018 ENTRESTO sacubitril/valsartan CHANGE UM: QUANTITY 60 / 30 days 60 / 30 DAYS 03/01/2018 ENTRESTO sacubitril/valsartan CHANGE TIER Non-Preferred 03/01/2018 HUMULIN R U- 500 KWIKPEN 03/01/2018 HUMULIN R U- 500 Preferred insulin regular, human CHANGE TIER Specialty Preferred insulin regular, human CHANGE TIER Specialty Preferred 03/01/2018 duloxetine hcl duloxetine hcl CHANGE UM: QUANTITY 90 / 30 days 90 / 30 DAYS 03/01/2018 PROAIR HFA albuterol sulfate CHANGE UM: QUANTITY 17 / 30 days 17 / 30 DAYS 03/01/2018 RENVELA sevelamer carbonate CHANGE TIER Specialty Preferred 03/01/2018 sevelamer carbonate 03/01/2018 sevelamer carbonate sevelamer carbonate Preferred sevelamer carbonate CHANGE TIER Specialty Preferred PAGE 9 UPDATED 09/2018
10 03/01/2018 RENVELA sevelamer carbonate CHANGE TIER Specialty Preferred 03/01/2018 sevelamer carbonate 03/01/2018 sevelamer carbonate sevelamer carbonate Preferred sevelamer carbonate CHANGE TIER Specialty Preferred 03/01/2018 RENVELA sevelamer carbonate CHANGE TIER Specialty Preferred 03/01/2018 EMBEDA morphine sulfate/naltrexone hcl 03/01/2018 EMBEDA morphine sulfate/naltrexone hcl CHANGE TIER Specialty Preferred CHANGE TIER Specialty Preferred PAGE 10 UPDATED 09/2018
11 April, /01/2018 medroxyprogeste rone acetate 04/01/2018 medroxyprogeste rone acetate medroxyprogesterone acetate medroxyprogesterone acetate 04/01/2018 altavera levonorgestrel-ethinyl 04/01/2018 kurvelo levonorgestrel-ethinyl CHANGE TIER CHANGE UM: QUANTITY 1 / 90 DAYS Preferred Preferred 04/01/2018 enskyce desogestrel-ethinyl Preferred 04/01/2018 SELZENTRY maraviroc 04/01/2018 EMFLAZA deflazacort 04/01/2018 EMFLAZA deflazacort 04/01/2018 EMFLAZA deflazacort 04/01/2018 EMFLAZA deflazacort 04/01/2018 EMFLAZA deflazacort 04/01/2018 levetiracetam er,roweepra xr levetiracetam CHANGE TIER Preferred 04/01/2018 HERCEPTIN trastuzumab 04/01/2018 SHINGRIX varicella-zoster virus glycoprotein e,rec/as01b adjuvant/pf 04/01/2018 ALUNBRIG brigatinib 04/01/2018 ALUNBRIG brigatinib ADD UM: QUANTITY 30 / 30 DAYS 04/01/2018 ALUNBRIG brigatinib PAGE 11 UPDATED 09/2018
12 04/01/2018 ALUNBRIG brigatinib ADD UM: QUANTITY 30 / 30 DAYS 04/01/2018 ALUNBRIG brigatinib 04/01/2018 ALUNBRIG brigatinib ADD UM: QUANTITY 60 / 365 OVER 04/01/2018 ELIQUIS apixaban 04/01/2018 ELIQUIS apixaban ADD UM: QUANTITY 148 / 368 OVER 04/01/2018 CINVANTI aprepitant 04/01/2018 ZENPEP lipase/protease/amylase 04/01/2018 Preferred 04/01/2018 tenofovir disoproxil fumarate tenofovir disoproxil fumarate Preferred 04/01/2018 atazanavir sulfate atazanavir sulfate Preferred 04/01/2018 atazanavir sulfate atazanavir sulfate Preferred 04/01/2018 atazanavir sulfate atazanavir sulfate Preferred 04/01/2018 doripenem doripenem Preferred 04/01/2018 levonorgestreleth levonorgestrel-ethinyl REMOVE UM: QUANTITY 91 / 91 days 04/01/2018 carvedilol er carvedilol phosphate Preferred 04/01/2018 carvedilol er carvedilol phosphate Preferred PAGE 12 UPDATED 09/2018
13 04/01/2018 carvedilol er carvedilol phosphate Preferred 04/01/2018 levetiracetam er,roweepra xr levetiracetam CHANGE TIER Preferred 04/01/2018 NUCALA mepolizumab CHANGE UM: QUANTITY 1 / 28 days 3 / 28 DAYS 04/01/2018 ZENPEP lipase/protease/amylase CHANGE TIER Specialty Preferred PAGE 13 UPDATED 09/2018
14 May, /01/2018 naloxone hcl naloxone hcl 05/01/2018 XTAMPZA ER oxycodone myristate Preferred 05/01/2018 XTAMPZA ER oxycodone myristate Preferred 05/01/2018 XTAMPZA ER oxycodone myristate Preferred 05/01/2018 XTAMPZA ER oxycodone myristate Preferred 05/01/2018 XTAMPZA ER oxycodone myristate Preferred 05/01/2018 haloperidol lactate 05/01/2018 QVAR REDIHALER 05/01/2018 QVAR REDIHALER 05/01/2018 QVAR REDIHALER 05/01/2018 QVAR REDIHALER haloperidol lactate beclomethasone dipropionate beclomethasone dipropionate beclomethasone dipropionate beclomethasone dipropionate ADD UM: QUANTITY ADD UM: QUANTITY Preferred 21.2 / 30 DAYS Preferred 21.2 / 30 DAYS 05/01/2018 SYMDEKO tezacaftor/ivacaftor Specialty 05/01/2018 SYMDEKO tezacaftor/ivacaftor ADD UM: QUANTITY 56 / 28 DAYS 05/01/2018 ERLEADA apalutamide Specialty 05/01/2018 ERLEADA apalutamide ADD UM: QUANTITY 120 / 30 DAYS 05/01/2018 BIKTARVY bictegravir sodium/emtricitabine/tenofov ir alafenamide fumar 05/01/2018 BIKTARVY bictegravir sodium/emtricitabine/tenofov ir alafenamide fumar ADD UM: QUANTITY Specialty 30 / 30 DAYS PAGE 14 UPDATED 09/2018
15 05/01/2018 sumatriptan succnaproxen sod 05/01/2018 sumatriptan succnaproxen sod sumatriptan succinate/naproxen sodium sumatriptan succinate/naproxen sodium ADD UM: QUANTITY Specialty 9 / 30 OVER 05/01/2018 digox digoxin 05/01/2018 ZENPEP lipase/protease/amylase Preferred 05/01/2018 ZENPEP lipase/protease/amylase Preferred 05/01/2018 digox digoxin ADD UM: QUANTITY 30 / 30 DAYS 05/01/2018 ENDARI glutamine Specialty 05/01/2018 isotretinoin isotretinoin Non-Preferred 05/01/2018 isotretinoin isotretinoin Non-Preferred 05/01/2018 isotretinoin isotretinoin Non-Preferred 05/01/2018 nolix flurandrenolide Non-Preferred 05/01/2018 efavirenz efavirenz Specialty 05/01/2018 abacavir abacavir sulfate 05/01/2018 VIDEX EC didanosine Non-Preferred 05/01/2018 trientine hcl trientine hcl Specialty 05/01/2018 efavirenz efavirenz Specialty 05/01/2018 isotretinoin isotretinoin Non-Preferred 05/01/2018 levonorg-eth estrad eth estrad levonorgestrel/ethinyl and ethinyl PAGE 15 UPDATED 09/2018
16 05/01/2018 levonorg-eth estrad eth estrad levonorgestrel/ethinyl and ethinyl ADD UM: QUANTITY 91 / 91 DAYS 05/01/2018 memantine hcl er memantine hcl 05/01/2018 memantine hcl er memantine hcl ADD UM: QUANTITY 30 / 30 DAYS 05/01/2018 memantine hcl er memantine hcl 05/01/2018 memantine hcl er memantine hcl ADD UM: QUANTITY 30 / 30 DAYS 05/01/2018 memantine hcl er memantine hcl 05/01/2018 memantine hcl er memantine hcl ADD UM: QUANTITY 30 / 30 DAYS 05/01/2018 memantine hcl er memantine hcl 05/01/2018 memantine hcl er memantine hcl ADD UM: QUANTITY 30 / 30 DAYS PAGE 16 UPDATED 09/2018
17 June, /01/2018 ABILIFY MAINTENA aripiprazole Specialty 06/01/2018 ALIMTA pemetrexed disodium Specialty 06/01/2018 DALIRESP roflumilast Non-Preferred 06/01/2018 EPIPEN 2-PAK epinephrine Preferred 06/01/2018 EPIPEN JR 2- PAK epinephrine Preferred 06/01/2018 glatopa glatiramer acetate Specialty 06/01/2018 glatopa glatiramer acetate ADD UM: QUANTITY 12 / 28 DAYS 06/01/2018 HAEGARDA c1 esterase inhibitor Specialty 06/01/2018 HAEGARDA c1 esterase inhibitor Specialty 06/01/2018 ILARIS canakinumab/pf Specialty 06/01/2018 ILARIS canakinumab/pf ADD UM: QUANTITY 2 / 28 DAYS 06/01/2018 IMBRUVICA ibrutinib Specialty 06/01/2018 IMBRUVICA ibrutinib Specialty 06/01/2018 IMBRUVICA ibrutinib Specialty 06/01/2018 IMBRUVICA ibrutinib Specialty 06/01/2018 IMBRUVICA ibrutinib Specialty 06/01/2018 INTRON A interferon alfa-2b,recomb. Specialty 06/01/2018 ISENTRESS HD raltegravir potassium Specialty 06/01/2018 lansoprazole lansoprazole Non-Preferred 06/01/2018 lansoprazole lansoprazole ADD UM: QUANTITY 30 / 30 DAYS PAGE 17 UPDATED 09/2018
18 06/01/2018 lansoprazole lansoprazole Non-Preferred 06/01/2018 lansoprazole lansoprazole ADD UM: QUANTITY 30 / 30 DAYS 06/01/2018 levoleucovorin calcium 06/01/2018 MAKENA hydroxyprogesterone caproate/pf 06/01/2018 melodetta 24 fe norethindrone acetateethinyl /ferrous fumarate levoleucovorin calcium Specialty Specialty 06/01/2018 mesalamine mesalamine Preferred 06/01/2018 ORFADIN nitisinone Preferred 06/01/2018 palonosetron hcl palonosetron hcl Non-Preferred 06/01/2018 PLEGRIDY peginterferon beta-1a Specialty 06/01/2018 PLEGRIDY peginterferon beta-1a ADD UM: QUANTITY 2 / 365 OVER 06/01/2018 RUBRACA rucaparib camsylate Specialty 06/01/2018 RUBRACA rucaparib camsylate ADD UM: QUANTITY 120 / 30 DAYS 06/01/2018 SYLVANT siltuximab Specialty 06/01/2018 SYMFI LO efavirenz/lamivudine/tenofov ir disoproxil fumarate 06/01/2018 SYMFI LO efavirenz/lamivudine/tenofov ir disoproxil fumarate ADD UM: QUANTITY Specialty 30 / 30 DAYS 06/01/2018 SYNAGIS palivizumab Specialty 06/01/2018 tiagabine hcl tiagabine hcl Non-Preferred 06/01/2018 tiagabine hcl tiagabine hcl Non-Preferred PAGE 18 UPDATED 09/2018
19 06/01/2018 TRESIBA FLEXTOUCH U /01/2018 TRESIBA FLEXTOUCH U /01/2018 tydemy drospirenone/ethinyl /levomefolate calcium insulin degludec Preferred insulin degludec Preferred Non-Preferred 06/01/2018 ZYTIGA abiraterone acetate Specialty 06/01/2018 diclofenac sodium 06/01/2018 hydrocortisonepramoxine diclofenac sodium CHANGE TIER Non-Preferred hydrocortisone acetate/pramoxine hcl 06/01/2018 kelnor 1-50 ethynodiol diacetate-ethinyl 06/01/2018 lamotrigine,lamot rigine (blue) 06/01/2018 lamotrigine,lamot rigine (green) 06/01/2018 lamotrigine,lamot rigine (orange) Non-Preferred lamotrigine lamotrigine Specialty lamotrigine 06/01/2018 palonosetron hcl palonosetron hcl 06/01/2018 ritonavir ritonavir 06/01/2018 triamcinolone acetonide triamcinolone acetonide 06/01/2018 VIRAMUNE nevirapine Specialty 06/01/2018 ORFADIN nitisinone CHANGE TIER Preferred Specialty PAGE 19 UPDATED 09/2018
20 July, /01/2018 HUMIRA adalimumab Specialty 07/01/2018 HUMIRA PEDIATRIC CROHN'S adalimumab Specialty 07/01/2018 HUMIRA PEN adalimumab Specialty 07/01/2018 HUMIRA PEDIATRIC CROHN'S adalimumab Specialty 07/01/2018 HUMIRA adalimumab Specialty 07/01/2018 BENZNIDAZOLE benznidazole Preferred 07/01/2018 ZENPEP lipase/protease/amylase Preferred 07/01/2018 BENZNIDAZOLE benznidazole Preferred 07/01/2018 syeda ethinyl /drospirenone 07/01/2018 tri-vylibra norgestimate-ethinyl 07/01/2018 vylibra norgestimate-ethinyl 07/01/2018 TOUJEO MAX SOLOSTAR 07/01/2018 methylphenidate la,methylphenidat e er 07/01/2018 methylphenidate la,methylphenidat e er insulin glargine,human recombinant analog Preferred methylphenidate hcl methylphenidate hcl ADD UM: QUANTITY 180 / 30 DAYS PAGE 20 UPDATED 09/2018
21 07/01/2018 methylphenidate er 07/01/2018 methylphenidate er methylphenidate hcl methylphenidate hcl ADD UM: QUANTITY 30 / 30 DAYS 07/01/2018 TASIGNA nilotinib hcl Specialty 07/01/2018 epinephrine epinephrine CHANGE TIER Non-Preferred Preferred PAGE 21 UPDATED 09/2018
22 August, /01/2018 baclofen baclofen 08/01/2018 ciprofloxacin hcl ciprofloxacin hcl 08/01/2018 colesevelam hcl colesevelam hcl Preferred 08/01/2018 estarylla norgestimate-ethinyl 08/01/2018 mili norgestimate-ethinyl 08/01/2018 tri-mili norgestimate-ethinyl 08/01/2018 SYNJARDY XR empagliflozin/metformin hcl Preferred 08/01/2018 SYNJARDY XR empagliflozin/metformin hcl ADD UM: QUANTITY 30 / 30 DAYS 08/01/2018 SYNJARDY XR empagliflozin/metformin hcl Preferred 08/01/2018 SYNJARDY XR empagliflozin/metformin hcl ADD UM: QUANTITY 60 / 30 DAYS 08/01/2018 SYNJARDY XR empagliflozin/metformin hcl Preferred 08/01/2018 SYNJARDY XR empagliflozin/metformin hcl ADD UM: QUANTITY 30 / 30 DAYS 08/01/2018 SYNJARDY XR empagliflozin/metformin hcl Preferred 08/01/2018 SYNJARDY XR empagliflozin/metformin hcl ADD UM: QUANTITY 60 / 30 DAYS 08/01/2018 HUMIRA adalimumab Specialty 08/01/2018 NORVIR ritonavir Specialty 08/01/2018 SYMFI efavirenz/lamivudine/tenofov ir disoproxil fumarate 08/01/2018 SYMFI efavirenz/lamivudine/tenofov ir disoproxil fumarate ADD UM: QUANTITY Specialty 30 / 30 DAYS 08/01/2018 TAVALISSE fostamatinib disodium Specialty PAGE 22 UPDATED 09/2018
23 08/01/2018 TAVALISSE fostamatinib disodium ADD UM: QUANTITY 60 / 30 DAYS 08/01/2018 TAVALISSE fostamatinib disodium Specialty 08/01/2018 TAVALISSE fostamatinib disodium ADD UM: QUANTITY 60 / 30 DAYS 08/01/2018 JYNARQUE tolvaptan Specialty 08/01/2018 JYNARQUE tolvaptan ADD UM: QUANTITY 56 / 28 DAYS 08/01/2018 JYNARQUE tolvaptan Specialty 08/01/2018 JYNARQUE tolvaptan ADD UM: QUANTITY 56 / 28 DAYS 08/01/2018 JYNARQUE tolvaptan Specialty 08/01/2018 JYNARQUE tolvaptan ADD UM: QUANTITY 56 / 28 DAYS 08/01/2018 cyclophosphamid e 08/01/2018 cyclophosphamid e cyclophosphamide CHANGE TIER Non-Preferred cyclophosphamide CHANGE TIER Non-Preferred 08/21/2018 GLEOSTINE lomustine Non-Preferred 08/21/2018 GLEOSTINE lomustine Non-Preferred 08/21/2018 GLEOSTINE lomustine Non-Preferred PAGE 23 UPDATED 09/2018
Upper Peninsula MI Health Link Updates
January, 2018 01/01/2018 TAMIFLU oseltamivir phosphate CHANGE UM: QUANTITY 720 / 365 days 720 / 365 OVER 01/01/2018 oseltamivir phosphate 01/01/2018 oseltamivir phosphate 01/01/2018 oseltamivir phosphate
HAP/Midwest Health Advantage MI Health Link (MMP) Updates
January, 2018 01/01/2018 hydrocortisone butyrate hydrocortisone butyrate 01/01/2018 MIRVASO brimonidine tartrate 01/01/2018 AZACTAM aztreonam 01/01/2018 AZACTAM aztreonam 01/01/2018 mesalamine mesalamine
Health Partners Medicare Special Formulary Updates
March 2018 Effective Date Brand Name Generic Name Type of Change 90 / 30 DAYS tenofovir disoproxil fumarate tenofovir disoproxil fumarate clobetasol propionate tenofovir disoproxil fumarate Previous Value
2018 Formulary Update
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You ll find the most up-to-date comprehensive version of our formulary on our website, Click on Drug Finder.
3/1/2018 Medicare Part D Formulary Change In an effort to cover the most needed, cost-effective prescriptions, the AlohaCare Advantage Plus (HMO SNP) Formulary is updated monthly. The following are drugs
NOTIFICATION OF FORMULARY CHANGES
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2018 Medicare Part D Formulary Change
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2018 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
Upper Peninsula Health Plan Advantage (HMO) (H ) Updates
February, 2017 02/28/2017 abacavirlamivudine 02/28/2017 abacavirlamivudine 02/28/2017 rasagiline mesylate 02/28/2017 rasagiline mesylate abacavir sulfate/lamivudine ADD UM: QUANTITY 30 / 30 Days abacavir
2018 CareOregon Advantage Part D Formulary Changes
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Health Partners Medicare Special (2017) Updates
March 2017 Effective Date Brand Name EVZIO erythromycin ethylsuccinate naloxone hcl Generic Name erythromycin ethylsuccinate Type of Change Previous Value New Value ofloxacin ofloxacin NAMZARIC NAMZARIC
Blue Shield 65 Plus Choice Plan (HMO) Blue Shield of California is an independent member of the Blue Shield Association. Formulary Updates:
Blue Shield 65 Plus Choice Plan (HMO) Formulary Updates: The enclosed table lists the changes made to your formulary such as removing or adding: a drug, prior authorization, quantity limits or step therapy
EFFECTIVE 01/05/2018. atazanavir sulfate 150 mg capsule - Added to Tier 1 TYPHIM VI 25 MCG/0.5 ML VIAL. - Added to Tier 2
EFFECTIVE 01/05/2018 atazanavir sulfate 150 mg capsule TYPHIM VI 25 MCG/0.5 ML VIAL typhoid vaccine vi capsular polysaccharide atazanavir sulfate 200 mg capsule atazanavir sulfate 300 mg capsule PAGE 1
Blue Cross and Blue Shield of Minnesota GenRx Formulary Updates
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Presbyterian Health Plan, Inc. Presbyterian Insurance Company, Inc. NOTIFICATION OF FORMULARY CHANGES
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CAREADVANTAGE (CMC/MMP) 2018 Updates
January, 2018 01/05/2018 atazanavir sulfate atazanavir sulfate 01/05/2018 TYPHIM VI typhoid vaccine vi capsular polysaccharide 01/12/2018 PROLASTIN C alpha-1-proteinase inhibitor 01/12/2018 01/12/2018
Blue Shield Rx Enhanced (PDP) Formulary Updates:
Blue Shield Rx Enhanced (PDP) Formulary Updates: The enclosed table lists the changes made to your such as removing or adding: a drug, prior authorization, quantity limits or step therapy as well as any
BlueLink TPA FlexRx Updates
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Blue Shield 65 Plus (HMO) Updates: The enclosed table lists the changes made to your such as removing or adding: a drug, prior authorization, quantity limits or step therapy as well as any changes to a
ELEVATE. Formulary Updates to Elevate Plans (Bronze HDHP/Standard, Silver Select/Standard & Gold Select/Standard)
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Medicare Part D 2017 Formulary Changes Service To Senior
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Drug 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
EFFECTIVE 01/02/2018 TYPHIM VI 25 MCG/0.5 ML VIAL. - Added to Tier 1. typhoid vaccine vi capsular polysaccharide
EFFECTIVE 01/02/2018 TYPHIM VI 25 MCG/0.5 ML VIAL typhoid vaccine vi capsular polysaccharide PAGE 1 LAST UPDATED 09/2018 EFFECTIVE 01/05/2018 atazanavir sulfate 150 mg capsule atazanavir sulfate 200 mg
Gundersen Senior Preferred MEDICARE 2018 PART D Updates
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Blue Cross and Blue Shield of Minnesota GenRx Formulary Updates
Blue Cross and Blue Shield of Minnesota GenRx Formulary Updates April 2018 TRADE NAME (generic name) or generic name Brand/Generic Description of Change abacavir sulfate soln 20 mg/ml (base equiv) Generic
Reason for change. Recently approved. Recently approved. Recently approved. Recently approved. Recently updated. Recently approved.
2017 Formulary Change Notice Please note these changes to your 2017 List of Covered Drugs Drug name (medication) Rubraca Aprepitant Onivyde Oseltamivir Restasis Xiidra Daptomycin Selzentry Linzess Butalb/APAP/caff
Health Partners Medicare Prime and Value (2017) Updates
March/April 2017 Effective Date Brand Name Name Type of Change Previous Value New Value SPS sodium polystyrene sulfonate/sorbitol solution ORKAMBI ADRENACLICK ADRENACLICK levalbuterol tartrate hfa EXONDYS
2018 Formulary Notice of Change Prescription Drug Plans
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Medicare Part D 2017 Formulary Changes OC Preferred
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Health Partners Medicare Prime and Value (2017) Updates
March/April 2017 Effective Date Brand Name Name Type of Change Previous Value New Value SPS sodium polystyrene sulfonate/sorbitol solution ORKAMBI ADRENACLICK ADRENACLICK levalbuterol tartrate hfa EXONDYS
2017 Formulary Changes Year to Date
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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
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VNSNY CHOICE FIDA Complete Step Therapy Requirements. Effective: 04/01/2019
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Aetna 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
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Step Therapy Requirements
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TennCare Program TN MAC Price Change List As of: 03/30/2017
1 TN List Run : 03/30/17 Old PRAZOSIN HCL 5 MG CAPSULE ORAL 03/29/2017 1.11209 1.12560 ( 1.2) CAPTOPRIL 12.5 MG TABLET ORAL 07/07/2015 1.07191 1.10416 ( 2.9) ISOSORBIDE DINITRATE 5 MG TABLET ORAL 03/29/2017
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Emblem 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
Added, Removed or Changed. Added, Removed or Changed
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Step Therapy Requirements. Effective: 11/01/2018
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Ambetter 90-Day-Supply Maintenance Drug List
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ANTIDEPRESSANTS. Details. dose pack Viibryd 10 mg tablet Viibryd 20 mg tablet Viibryd 40 mg tablet. Criteria
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TN Cover Rx Tennessee CoverRx MAC Price Change List As of: 04/26/2018
1 Tennessee CoverRx List Run : 04/26/18 Dosage Form amiodarone HCl 200 MG TABLET ORAL 04/25/2018 0.16102 0.14405 11.8 hydralazine HCl 100 MG TABLET ORAL 04/25/2015 0.11390 0.10854 4.9 hydralazine HCl 25
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Step Therapy Requirements. Effective: 12/01/2016
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Nebraska Medicaid Program NE Weekly MAC Price Change List For Period: 12/14/ /20/2017
1 Medicaid Run : 12/21/17 NE Weekly List Old AMIODARONE HCL 200 MG TABLET ORAL 12/20/2017 0.15321 0.14370 6.6 HYDRALAZINE HCL 10 MG TABLET ORAL 12/20/2017 0.05226 0.05213 0.2 LISINOPRIL 10 MG TABLET ORAL
COMMERCIAL APIs. S. No Molecule Name Therapeutic Category USDMF EDMF CEP IH
1 Abacavir Sulphate Antiretroviral - * - 2 Abiraterone Acetate Oncology - - - 3 Albendazole Anti-infective - - - 4 Albuterol Sulphate Respiratory - - 5 Alendronate Sodium Trihydrate Metabolic Disorder
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Formulary (List of Drugs)
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Step Therapy Requirements. Effective: 05/01/2018
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AMANTADINE ER. Products Affected Step 2: OSMOLEX ER 129 MG TABLET, EXTENDED RELEASE OSMOLEX ER 193 MG TABLET, Details
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VIVA MEDICARE IMPORTANT T EXPANDED PERFORMANCE FORMULARY UPDATES
NORE/ETH/FER CHW 0.MG Added to the 07 //07 ALYACEN TAB / Added to the 07 //07 AMETHIA LO TAB Added to the 07 //07 ERGOT/CAFFEN TAB 00MG Added to the 07 //07 NORETH/ETHIN TAB /0 Added to the 07 //07 LORCET
PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES Select Formulary October 1, 2018 Updates. Formulary. Alternatives
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March 2018 Pharmacy & Therapeutics Committee Decisions
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Active Pharmaceutical Ingredient (API) List List Updated March 1st, 2019
5-Fluorouracil 5-FU, Fluorouracil Stability Indicating HPLC-UV USP 7-keto DHEA Stability Indicating HPLC-UV Medisca Tier 1 Acetaminophen Stability Indicating HPLC-UV USP Adenosine Alprostadil PGE-1, Prostaglandin
Partners Notice of Change March 2017
New Added Products: Effective 3/1/2017 Drug Reason Tier Restrictions abacavir 600 mg-lamivudine 300 QL ADRENACLICK 0.15 MG/0.15 ML INJECTION,AUTO- INJECTOR ADRENACLICK 0.3 MG/0.3 ML INJECTION, AUTO- INJECTOR
TABLE OF CONTENTS (Click on a link below to view the section.)
Follow the links below to access the complete formularies for Plans: Health Plan Acne Allergy Allergic Anaphylactic Reaction Allergic Conjunctivitis Allergic Rhinitis Asthma Atopic Dermatitis Behavioral
INJECTION, INOTUZUMAB OZOGAMICIN, 0.1 MG [BESPONSA ] [C CODES FOR FACILITY USE ONLY]
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Commercial Medical Oncology Program Review Code List 3rd Quarter 2018 This list is subject to change once per quarter. Changes will be posted to the BCBSNC website at www.bcbsnc.com by the 10th day of
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