2017 Medicare Part D Formulary Change

Transcription

1 2017 Medicare Part D Formulary Change We may add or remove drugs from our formulary during the year. If we remove drugs from our formulary, or add prior authorizations, quantity limits and/or step therapy restrictions on a drug [or move a drug to a higher cost-sharing tier], we will let you know of the change at least 60 days before the date that the change becomes effective. However, if the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and let you know. The product changes noted below will be implemented on the Medicare Part D Plan formulary. To see if your drug is on this list, please refer to the tables below: New Added Products: Effective 3/1/2017 ABACAVIR 600 MG-LAMIVUDINE 300 MG ADRIAMYCIN 20 MG/10 ML INTRAVENOUS 1 Drug Cost sharing Restrictions* ALA-CORT 2.5 % TOPICAL CREAM ALLOPURINOL 500 MG INTRAVENOUS ALYACEN 1/35 (28) 1 MG-35 MCG AMETHIA LO 0.10 MG-20 MCG (84)/10 MCG(7) S,3 MONTH DOSE CK AMLODIPINE 10 MG-OLMESARTAN 20 MG AMLODIPINE 10 MG-OLMESARTAN 40 MG AMLODIPINE 5 MG-OLMESARTAN 20 MG AMLODIPINE 5 MG-OLMESARTAN 40 MG APREPITANT 125 MG (1)-80 MG (2) CAPSULES IN A DOSE CK APREPITANT 125 MG CAPSULE APREPITANT 40 MG CAPSULE

2 Drug Cost sharing Restrictions* APREPITANT 80 MG CAPSULE AZITHROMYCIN 500 MG (3 CK) BETIMOL 0.5 % EYE DROPS BUPROPION HCL 150 MG,SUSTAINED RELEASE (AS A SMOKING DETERRENT) CAMRESE LO 0.10 MG-20 MCG (84)/10 MCG(7) S,3 MONTH DOSE CK CAZIANT (28) 0.1 MG/0.125 MG/0.15 MG-25 MCG CHOLESTYRAMINE LIGHT 4 GRAM ORAL POWDER CLINDAMYCIN 1.2 % (1 % BASE)-BENZOYL PEROXIDE 5 % TOPICAL GEL DAPTOMYCIN 500 MG INTRAVENOUS DROSPIREN-E.ESTRAD-L.MEFOL 3 MG-0.02 MG MG(24)/0.451 MG(4) EMEND 125 MG (25 MG/ML FINAL CONC.) ORAL SUSPENSION EPCLUSA 400 MG-100 MG EPIRUBICIN 200 MG/100 ML INTRAVENOUS ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML ORAL POWDER FOR SUSPENSION EZETIMIBE 10 MG FLUOCINONIDE-E 0.05% TOPICAL CREAM GAMMAGARD S-D (IGA < 1 MCG/ML) 10 GRAM INTRAVENOUS GAMMAGARD S-D (IGA < 1 MCG/ML) 5 GRAM INTRAVENOUS GENGRAF 50 MG CAPSULE HUMIRA PEN PSORIASIS-UVEITIS STARTER 40 MG/0.8 ML SUBCUTANEOUS KIT IMOGAM RABIES-HT (PF) 150 UNIT/ML INTRAMUSCULAR KINRIX (PF) 25 LF-58 MCG-10 LF/0.5 ML INTRAMUSCULAR SYRINGE Tier 3 2

3 Drug Cost sharing Restrictions* KYPROLIS 30 MG INTRAVENOUS KYPROLIS 60 MG INTRAVENOUS LARISSIA 0.1 MG-20 MCG LARTRUVO 10 MG/ML INTRAVENOUS LEVALBUTEROL 1.25 MG/0.5 ML FOR NEBULIZATION (2.5 MG/ML) LOW-OGESTREL (28) 0.3 MG-30 MCG METHOTREXATE SODIUM 25 MG/ML INJECTION MORGIDOX 50 MG CAPSULE MYCOPHENOLATE 500 MG INTRAVENOUS NECON 1/50 (28) 1 MG-50 MCG NIFEDIPINE ER 30 MG,EXTENDED NIFEDIPINE ER 60 MG,EXTENDED NIFEDIPINE ER 90 MG,EXTENDED NILUTAMIDE 150 MG NITROGLYCERIN 0.3 MG SUBLINGUAL NITROGLYCERIN 0.4 MG SUBLINGUAL NITROGLYCERIN 0.6 MG SUBLINGUAL NORETHIN-ETHINYL ESTRADIOL-IRON 0.4 MG- 35 MCG(21)/75 MG(7) CHEW NORGESTIMATE 0.18 MG/0.215 MG/0.25 MG- ETHINYL ESTRADIOL 25 MCG NORGESTIMATE-ETHINYL ESTRADIOL 0.18 MG/0.215MG/0.25MG-35 MCG(28) OFLOXACIN 300 MG OLMESARTAN 20 MG OLMESARTAN 20 MG-AMLODIPINE 5 MG- HYDROCHLOROTHIAZIDE 12.5 MG OLMESARTAN 20 MG-HYDROCHLOROTHIAZIDE 12.5 MG 3

4 Drug Cost sharing Restrictions* OLMESARTAN 40 MG OLMESARTAN 40 MG-AMLODIPINE 10 MG- HYDROCHLOROTHIAZIDE 12.5 MG OLMESARTAN 40 MG-AMLODIPINE 10 MG- HYDROCHLOROTHIAZIDE 25 MG OLMESARTAN 40 MG-AMLODIPINE 5 MG- HYDROCHLOROTHIAZIDE 12.5 MG OLMESARTAN 40 MG-AMLODIPINE 5 MG- HYDROCHLOROTHIAZIDE 25 MG OLMESARTAN 40 MG-HYDROCHLOROTHIAZIDE 12.5 MG OLMESARTAN 40 MG-HYDROCHLOROTHIAZIDE 25 MG OLMESARTAN 5 MG ORKAMBI 100 MG-125 MG OSELTAMIVIR 30 MG CAPSULE OSELTAMIVIR 45 MG CAPSULE OSELTAMIVIR 75 MG CAPSULE NCREAZE 2,600 UNIT-6,200 UNIT-10,850 UNIT CAPSULE,DELAYED RELEASE PEDIARIX (PF) 10 MCG-25 LF-25 MCG-10 LF/0.5 ML INTRAMUSCULAR SYRINGE PRAMIPEXOLE ER 3.75 MG,EXTENDED Tier 3 PREDNISONE 10 MG S IN A DOSE CK Tier 1 PREDNISONE 10 MG S IN A DOSE CK (48 CK) Tier 1 PREDNISONE 5 MG S IN A DOSE CK Tier 1 PREDNISONE 5 MG S IN A DOSE CK (48 CK) QUETIAPINE ER 150 MG,EXTENDED QUETIAPINE ER 200 MG,EXTENDED QUETIAPINE ER 300 MG,EXTENDED Tier 1 4

5 QUETIAPINE ER 400 MG,EXTENDED QUETIAPINE ER 50 MG,EXTENDED Drug Cost sharing Restrictions* RASAGILINE 0.5 MG RASAGILINE 1 MG RETHA PUSHTRONEX 420 MG/3.5 ML SUBCUTANEOUS WEARABLE INJECTOR RUBRACA 200 MG LA RUBRACA 300 MG LA SPS (WITH SORBITOL) 15 GRAM-20 GRAM/60 ML ORAL SUSPENSION SUBOXONE 12 MG-3 MG SUBLINGUAL FILM SUBOXONE 2 MG-0.5 MG SUBLINGUAL FILM SUBOXONE 4 MG-1 MG SUBLINGUAL FILM SUBOXONE 8 MG-2 MG SUBLINGUAL FILM SUMATRIPTAN 4 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR TRIAMCINOLONE ACETONIDE 55 MCG NASAL SPRAY AEROSOL VALGANCICLOVIR 50 MG/ML ORAL VIVITROL 380 MG INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE YONDELIS 1 MG INTRAVENOUS ZARAH 3 MG-0.03 MG ZERIT 1 MG/ML ORAL 5

6 Future Removed Products: Effective 3/1/2017 Drug A-HYDROCORT 100 MG FOR INJECTION BUPROBAN 150 MG,EXTENDED RELEASE CERVARIX VACCINE (PF) 20 MCG-20 MCG/0.5 ML INTRAMUSCULAR SYRINGE FORTICAL 200 UNIT/ACTUATION NASAL SPRAY GILDESS 1.5/30 (21) 1.5 MG-30 MCG MELOXICAM 7.5 MG/5 ML ORAL SUSPENSION METHYLERGONOVINE 0.2 MG NAPHAZOLINE 0.1 % EYE DROPS NIFEDICAL XL 30 MG,EXTENDED RELEASE NIFEDICAL XL 60 MG,EXTENDED RELEASE PLASMA-LYTE-56 IN 5 % DEXTROSE INTRAVENOUS RANITIDINE 25 MG/ML INJECTION RESERPINE 0.1 MG RESERPINE 0.25 MG STAVUDINE 1 MG/ML ORAL TRAVOPROST (BENZALKONIUM) % EYE DROPS TYVASO 1.74 MG/2.9 ML (0.6 MG/ML) FOR NEBULIZATION TYZEKA 600 MG VARIZIG 125 UNIT/1.2 ML INTRAMUSCULAR VITEKTA 150 MG VITEKTA 85 MG Reason 6

7 Cost Sharing Tier Changes: Effective 3/1/2017 Drug New Tier Old Tier Restrictions* LOSARTAN 100 MG-HYDROCHLOROTHIAZIDE 12.5 MG LOSARTAN 100 MG-HYDROCHLOROTHIAZIDE 25 MG LOSARTAN 50 MG-HYDROCHLOROTHIAZIDE 12.5 MG

8 For more information about how these changes may affect your cost-sharing, such as copayments or coinsurance, or for more information about asking for an updated coverage determination or a formulary exception, please see the plan Evidence of Coverage. Alternative drugs are drugs in the same therapeutic category/class as the affected drug. Only your doctor can determine alternative drugs that are appropriate for you given the individualized nature of drug therapy. Please talk to your doctor about any changes or recommendations to your medical care and prescription drug therapy. Alternative drugs and additional information about formulary changes can be found on the plan formulary, *Indicates a restriction of Step Therapy, Prior Authorization or Quantity Level Limits may exit LA = Limited Access, = Prior Authorization, = Quantity Limit, ST = Step Therapy Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayment/coinsurance may change on January 1, 2018 This document includes GuildNet Gold and GuildNet Health Advantage partial formulary as of 03/01/2017. For a complete, updated formulary, please visit our Web site at or call the Member Service number below. This information is available for free in other languages. Please contact Member Services number at for additional information. (TTY users should call ). Hours are Monday through Friday, 8am -8pm. Member Services has free language interpreter services available for non-english speakers. Esta información esta disponible en otros idiomas a gratis. Por favor llame a Servicios a los Clientes, al por información adicional. (Los usuarios de TTY deben llamar al ). Se atiende de lunes a viernes, de 8 a. m. a 8 p. m. Servicios a los Clientes tienen los servicios gratuitos de intérprete de idioma disponibles para altavoces de no-inglés. GuildNet Gold and GuildNet Health Advantage are HMO-POS SNP plans with Medicare and New York State contracts. Enrollment in GuildNet Gold and GuildNet Health Advantage depends on contract renewal. 8