SecureBlue Formulary 2016 Master Negative Changes from 2015 to 2016

Size: px
Start display at page:

Download "SecureBlue Formulary 2016 Master Negative Changes from 2015 to 2016"

Transcription

1 Beta-lactam, SUPRAX TAB 400MG Suprax 400 mg cap Antibacterials Cephalosporins Beta-lactam, CEFOTAXIME INJ 10GM cefotaxime 2 gm inj Antibacterials Cephalosporins ERYTHROCIN INJ 1000MG Erythrocin 500 mg inj Antibacterials Macrolides TETRACYCLINE CAP 250MG doxycycline monohydrate cap or tab (50mg, 75mg, 100mg, 150mg), doxycycline hyclate cap (50mg, 100mg), doxycycline hyclate tab (20mg, 100mg), minocycline cap or tab (50mg, 75mg, 100mg) Antibacterials Tetracyclines TETRACYCLINE CAP 500MG doxycycline monohydrate cap or tab (50mg, 75mg, 100mg, 150mg), doxycycline hyclate cap (50mg, 100mg), doxycycline hyclate tab (20mg, 100mg), minocycline cap or tab (50mg, 75mg, 100mg) Antibacterials Tetracyclines fluconazole/inj NACL 200mg/100ml or FLUCONAZOLE/ INJ NACL mg/200mL Antifungals Antifungals EPIVIR VALCYTE SOL 10MG/ML TAB 450MG SecureBlue Formulary 2016 Master Negative Changes from 2015 to 2016 lamivudine 10mg/ml oral solution Antivirals valganciclovir 450mg tab Antivirals Anti-HIV, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) Anti-cytomegalovirus (CMV) Pg. 1 of 22

2 Anti-hepatitis B (HBV) BARACLUDE TAB 0.5MG entecavir 0.5 mg tab Antivirals BARACLUDE TAB 1MG entecavir 1 mg tab Antivirals Anti-hepatitis B (HBV) Anti-hepatitis B (HBV) VIRAZOLE INH 6GM check with your doctor Antivirals STROMECTOL TAB 3MG ivermectin 3mg tab Antiparasitics Anthelmintics METRONIDAZOL CAP 375MG metronidazole tab (250mg, 500mg) Antibacterials Antibacterials, VANCOMYC/DEX INJ 500MG vancomycin 500mg inj Antibacterials Antibacterials, VANCOMYC/DEX INJ 750MG vancomycin inj (500mg or 1 gm) Antibacterials Antibacterials, VANCOMYC/DEX INJ 1GM vancomycin 1 gm inj Antibacterials Antibacterials, linezolid tab* *Please note, this formulary alternative or ZYVOX TAB 600MG for more information. Antibacterials Antibacterials, ZYVOX SOL 2MG/ML linezolid inj Antibacterials Antibacterials, TETANUS TOX INJ 5LF ADS check with your doctor Immunological Vaccines Pg. 2 of 22

3 CYTARABINE INJ 100MG Not on formulary because does not meet the definition of a Part D drug under CMS regulations Cytarabine inj* (20mg/ml, 100mg/ml) *Please note, this formulary alternative or for more information. Antineoplastics Antineoplastics, Cytarabine inj* (20mg/ml, 100mg/ml) *Please note, this formulary alternative CYTARABINE INJ 1GM Not on formulary because does not meet the definition of a Part D drug under CMS regulations or for more information. Antineoplastics Antineoplastics, DOCEFREZ INJ 80MG docetaxel inj Antineoplastics Antineoplastics, VINBLASTINE INJ 10MG Not on formulary because does not meet the definition of a Part D drug under CMS regulations vinblastine 1mg/ml* *Please note, this formulary for more information. Antineoplastics Antineoplastics, Pg. 3 of 22

4 ANDROGEL GEL 1%(25MG) ANDROGEL GEL 1%(50MG) ANDROGEL GEL PUMP 1% Androderm* *Please note, this formulary alternative or Hormonal, Stimulant/ Replacement/ Modifying (Sex Hormones/ for more information. Modifiers) Androderm* *Please note, this formulary alternative or Hormonal, Stimulant/ Replacement/ Modifying (Sex Hormones/ for more information. Modifiers) Androderm* *Please note, this formulary alternative or Hormonal, Stimulant/ Replacement/ Modifying (Sex Hormones/ for more information. Modifiers) Androgens Androgens Androgens Pg. 4 of 22

5 ANDROGEL GEL 1.62% ANDROGEL GEL 1.62% Androderm* *Please note, this formulary alternative or Hormonal, Stimulant/ Replacement/ Modifying (Sex Hormones/ for more information. Modifiers) Androderm* *Please note, this formulary alternative or Hormonal, Stimulant/ Replacement/ Modifying (Sex Hormones/ for more information. Modifiers) Androgens Androgens Androderm* *Please note, this formulary alternative or Hormonal, Stimulant/ Replacement/ Modifying (Sex Hormones/ ANDROGEL GEL 1.62% for more information. Modifiers) Therapeutic Nutrients/ LEVOCARNITIN TAB 330MG check with your doctor Minerals/ Electrolytes LEVOCARNITIN SOL 1GM/10ML check with your doctor Therapeutic Nutrients/ Minerals/ Electrolytes Androgens Therapeutic Nutrients/ Minerals/ Electrolytes Therapeutic Nutrients/ Minerals/ Electrolytes Pg. 5 of 22

6 PROPRANOLOL TAB 60MG PROPRANOLOL CAP 60MG ER PROPRANOLOL CAP 80MG ER PROPRANOLOL CAP 120MG ER PROPRANOLOL CAP 160MG ER BISOPROL FUM TAB 5MG BISOPROL FUM TAB 10MG CANDESARTAN TAB 4MG CANDESARTAN TAB 8MG CANDESARTAN TAB 16MG CANDESARTAN TAB 32MG EPROSART MES TAB 600MG BENICAR TAB 5MG propranolol 10mg, 20mg, 40mg or 80mg tab propranolol 10mg, 20mg, 40mg or 80mg tab propranolol 10mg, 20mg, 40mg or 80mg tab propranolol 10mg, 20mg, 40mg or 80mg tab propranolol 10mg, 20mg, 40mg or 80mg tab acebutolol, atenolol, metoprolol tartrate or metoprolol succinate ER acebutolol, atenolol, metoprolol tartrate or metoprolol succinate ER irbesartan, losartan potassium, telmisartan or valsartan irbesartan, losartan potassium, telmisartan or valsartan irbesartan, losartan potassium, telmisartan or valsartan irbesartan, losartan potassium, telmisartan or valsartan irbesartan, losartan potassium, telmisartan or valsartan irbesartan, losartan potassium, telmisartan or valsartan Beta-adrenergic Blocking Beta-adrenergic Blocking Beta-adrenergic Blocking Beta-adrenergic Blocking Beta-adrenergic Blocking Beta-adrenergic Blocking Beta-adrenergic Blocking Angiotensin II Receptor Antagonists Angiotensin II Receptor Antagonists Angiotensin II Receptor Antagonists Angiotensin II Receptor Antagonists Angiotensin II Receptor Antagonists Angiotensin II Receptor Antagonists Pg. 6 of 22

7 BENICAR TAB 20MG BENICAR TAB 40MG irbesartan, losartan potassium, telmisartan or valsartan irbesartan, losartan potassium, telmisartan or valsartan AZOR TAB 5-20MG amlodipine/valsartan AZOR TAB 5-40MG amlodipine/valsartan AZOR TAB 10-20MG amlodipine/valsartan AZOR TAB 10-40MG amlodipine/valsartan EXFORGE TAB 5-160MG amlodipine/valsartan tab EXFORGE TAB 5-320MG amlodipine/valsartan tab EXFORGE TAB MG amlodipine/valsartan tab EXFORGE TAB MG amlodipine/valsartan tab irbesartan/hydrochlorothiazi de, losartan/hydrochlorothiazid e, telmisartan/hydrochlorothia zide or valsartan/hydrochlorothiazi CANDESA/HCTZ TAB de Angiotensin II Receptor Antagonists Angiotensin II Receptor Antagonists,,,,,,,,, Pg. 7 of 22

8 CANDESA/HCTZ TAB CANDESA/HCTZ TAB 32-25MG BENICAR HCT TAB BENICAR HCT TAB irbesartan/hydrochlorothiazi de, losartan/hydrochlorothiazid e, telmisartan/hydrochlorothia zide or valsartan/hydrochlorothiazi de irbesartan/hydrochlorothiazi de, losartan/hydrochlorothiazid e, telmisartan/hydrochlorothia zide or valsartan/hydrochlorothiazi de irbesartan/hydrochlorothiazi de, losartan/hydrochlorothiazid e, telmisartan/hydrochlorothia zide or valsartan/hydrochlorothiazi de irbesartan/hydrochlorothiazi de, losartan/hydrochlorothiazid e, telmisartan/hydrochlorothia zide or valsartan/hydrochlorothiazi de,,,, Pg. 8 of 22

9 BENICAR HCT TAB 40-25MG EXFORGEH/5- TAB EXFORGEH/5- TAB EXFORGEH/10- TAB EXFORGEH/10- TAB EXFORGEH/10- TAB TRIBENZOR20- TAB MG TRIBENZOR40- TAB MG TRIBENZOR40- TAB 5-25MG TRIBENZOR40- TAB TRIBENZOR40- TAB 10-25MG irbesartan/hydrochlorothiazi de, losartan/hydrochlorothiazid e, telmisartan/hydrochlorothia zide or valsartan/hydrochlorothiazi de amlodipine/valsartan/hydro chlorothiazide tab amlodipine/valsartan/hydro chlorothiazide tab amlodipine/valsartan/hydro chlorothiazide tab amlodipine/valsartan/hydro chlorothiazide tab amlodipine/valsartan/hydro chlorothiazide tab amlodipine/valsartan/hydro chlorothiazide tab amlodipine/valsartan/hydro chlorothiazide tab amlodipine/valsartan/hydro chlorothiazide tab amlodipine/valsartan/hydro chlorothiazide tab amlodipine/valsartan/hydro chlorothiazide tab,,,,,,,,,,, WELCHOL TAB 625MG cholestyramine powder, cholestyramine lite powder, Prevalite or colestipol Blood Glucose Regulators Antidiabetic Respiratory Tract/ CLEMASTINE TAB 2.68MG levocetirizine Pulmonary Antihistamines Pg. 9 of 22

10 NASONEX SPR 50MCG/AC ASTEPRO SPR 0.15% flunisolide or fluticasone nasal spray azelastine nasal spray Respiratory Tract/ Pulmonary Respiratory Tract/ Pulmonary Anti-inflammatories, Inhaled Corticosteroids Antihistamines ALBUTEROL TAB 4MG ER albuterol immediate release tab or terbutaline tab Respiratory Tract/ Pulmonary Bronchodilators, Sympathomimetic ALBUTEROL TAB 8MG ER KALYDECO TAB 150MG authorization KALYDECO PAK 50MG authorization KALYDECO PAK 75MG authorization NEXIUM GRA 2.5MG DR NEXIUM GRA 5MG DR NEXIUM GRA 10MG DR NEXIUM GRA 20MG DR NEXIUM GRA 40MG DR NEXIUM CAP 20MG NEXIUM CAP 20MG NEXIUM CAP 40MG NEXIUM CAP 40MG albuterol immediate release Respiratory Tract/ Bronchodilators, tab or terbutaline tab Pulmonary Sympathomimetic Respiratory Tract/ check with your doctor Pulmonary Cystic Fibrosis Respiratory Tract/ check with your doctor Pulmonary Cystic Fibrosis Respiratory Tract/ check with your doctor Pulmonary Cystic Fibrosis omeprazole cap or pantoprazole tab Gastrointestinal Proton Pump Inhibitors omeprazole cap or pantoprazole tab Gastrointestinal Proton Pump Inhibitors omeprazole cap or pantoprazole tab Gastrointestinal Proton Pump Inhibitors omeprazole cap or pantoprazole tab Gastrointestinal Proton Pump Inhibitors omeprazole cap or pantoprazole tab Gastrointestinal Proton Pump Inhibitors omeprazole cap or pantoprazole tab Gastrointestinal Proton Pump Inhibitors omeprazole cap or pantoprazole tab Gastrointestinal Proton Pump Inhibitors omeprazole cap or pantoprazole tab Gastrointestinal Proton Pump Inhibitors omeprazole cap or pantoprazole tab Gastrointestinal Proton Pump Inhibitors Pg. 10 of 22

11 GRANISETRON TAB 1MG ondansetron (regular, ODT) tab* *Please note, this formulary alternative or for more information. Antiemetics Emetogenic Therapy Adjuncts ONDANSETRON SOL 4MG/5ML LOTRONEX LOTRONEX TAB 0.5MG TAB 1MG ondansetron (regular, ODT) tab* *Please note, this formulary alternative or for more information. Antiemetics Emetogenic Therapy Adjuncts Irritable Bowel Syndrome alosetron Gastrointestinal Irritable Bowel Syndrome alosetron Gastrointestinal authorization check with your doctor Antibacterials Antibacterials, NITROFURANTN CAP 100MG TERCONAZOLE SUP 80MG terconazole cream Antifungals Antifungals ZAZOLE SUP 80MG terconazole cream Antifungals Antifungals Pg. 11 of 22

12 ALPRAZOLAM TAB 0.25MG buspirone tab, clorazepate tab*, diazepam tab*, lorazepam tab* *Please note, these formulary alternatives require prior for more information. Anxiolytics Anxiolytics ALPRAZOLAM TAB 0.5MG buspirone tab, clorazepate tab*, diazepam tab*, lorazepam tab* *Please note, these formulary alternatives require prior for more information. Anxiolytics Anxiolytics Pg. 12 of 22

13 ALPRAZOLAM TAB 1MG buspirone tab, clorazepate tab*, diazepam tab*, lorazepam tab* *Please note, these formulary alternatives require prior for more information. Anxiolytics Anxiolytics ALPRAZOLAM TAB 2MG SEROQUEL XR TAB 50MG SEROQUEL XR TAB 150MG buspirone tab, clorazepate tab*, diazepam tab*, lorazepam tab* *Please note, these formulary alternatives require prior for more information. Anxiolytics Anxiolytics If drug taken in 2015, coverage will occur until On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical If drug taken in 2015, coverage will occur until On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical Pg. 13 of 22

14 SEROQUEL XR TAB 200MG SEROQUEL XR TAB 300MG SEROQUEL XR TAB 400MG If drug taken in 2015, coverage will occur until On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical If drug taken in 2015, coverage will occur until On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical If drug taken in 2015, coverage will occur until On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical ABILIFY TAB 2MG aripiprazole tab* *Please note, this formulary for more information. Antipsychotics 2nd Generation/Atypical ABILIFY TAB 5MG aripiprazole tab* *Please note, this formulary for more information. Antipsychotics 2nd Generation/Atypical Pg. 14 of 22

15 ABILIFY TAB 10MG aripiprazole tab* *Please note, this formulary for more information. Antipsychotics 2nd Generation/Atypical ABILIFY TAB 15MG aripiprazole tab* *Please note, this formulary for more information. Antipsychotics 2nd Generation/Atypical ABILIFY TAB 20MG aripiprazole tab* *Please note, this formulary for more information. Antipsychotics 2nd Generation/Atypical Pg. 15 of 22

16 ABILIFY TAB 30MG aripiprazole tab* *Please note, this formulary for more information. Antipsychotics 2nd Generation/Atypical ABILIFY SOL 1MG/ML ABILIFY INJ 9.75MG aripiprazole oral solution* *Please note, this formulary for more information. Antipsychotics 2nd Generation/Atypical Geodon inj* or olanzapine inj* *Please note, these formulary alternatives require prior authorization. or for more information. Antipsychotics 2nd Generation/Atypical Pg. 16 of 22

17 ABILIFY DISC TAB 15MG ESZOPICLONE TAB 1MG ESZOPICLONE TAB 2MG ESZOPICLONE TAB 3MG ZALEPLON CAP 5MG ZALEPLON CAP 10MG aripiprazole tab* *Please note, this formulary for more information. Antipsychotics 2nd Generation/Atypical authorization check with your doctor Sleep Disorder GABA Receptor Modulators authorization check with your doctor Sleep Disorder GABA Receptor Modulators authorization check with your doctor Sleep Disorder GABA Receptor Modulators authorization check with your doctor Sleep Disorder GABA Receptor Modulators authorization check with your doctor Sleep Disorder GABA Receptor Modulators EXELON DIS 4.6MG/24 rivastigmine cap (1.5mg, 3mg, 4.5mg, 6mg), donepezil or memantine* *Please note, this formulary for more information. Antidementia Cholinesterase Inhibitors Pg. 17 of 22

18 EXELON DIS 9.5MG/24 rivastigmine cap (1.5mg, 3mg, 4.5mg, 6mg), donepezil or memantine* *Please note, this formulary for more information. Antidementia Cholinesterase Inhibitors EXELON DIS 13.3/24 MEMANTINE TAB HCL 5MG MEMANTINE HC TAB 10MG rivastigmine cap (1.5mg, 3mg, 4.5mg, 6mg), donepezil or memantine* *Please note, this formulary for more information. Antidementia Cholinesterase Inhibitors authorization check with your doctor Antidementia authorization check with your doctor Antidementia N-methyl-D-aspartate (NMDA) Receptor Antagonist N-methyl-D-aspartate (NMDA) Receptor Antagonist Pg. 18 of 22

19 MEMANT TITRA PAK 5-10MG NAMENDA SOL 10MG/5ML NAMENDA XR CAP 7MG NAMENDA XR CAP 14MG NAMENDA XR CAP 21MG NAMENDA XR CAP 28MG NAMENDA XR CAP TITRATIO FLURBIPROFEN TAB 50MG FLURBIPROFEN TAB 100MG authorization check with your doctor Antidementia authorization check with your doctor Antidementia authorization check with your doctor Antidementia authorization check with your doctor Antidementia authorization check with your doctor Antidementia authorization check with your doctor Antidementia authorization check with your doctor Antidementia diclofenac, etodolac, ibuprofen, ketoprofen, meloxicam, nabumetone, naproxen, oxaprozin, piroxicam, sulindac or tolmetin Analgesics diclofenac, etodolac, ibuprofen, ketoprofen, meloxicam, nabumetone, naproxen, oxaprozin, piroxicam, sulindac or tolmetin Analgesics N-methyl-D-aspartate (NMDA) Receptor Antagonist N-methyl-D-aspartate (NMDA) Receptor Antagonist N-methyl-D-aspartate (NMDA) Receptor Antagonist N-methyl-D-aspartate (NMDA) Receptor Antagonist N-methyl-D-aspartate (NMDA) Receptor Antagonist N-methyl-D-aspartate (NMDA) Receptor Antagonist N-methyl-D-aspartate (NMDA) Receptor Antagonist Nonsteroidal Antiinflammatory Drugs Nonsteroidal Antiinflammatory Drugs Pg. 19 of 22

20 LEVETIRACETA INJ 5MG/ML LEVETIRACETA INJ 10MG/ML LEVETIRACETA INJ 15MG/ML levetiracetam 500mg/5mL inj Anticonvulsants Anticonvulsants, levetiracetam 500mg/5mL inj Anticonvulsants Anticonvulsants, levetiracetam 500mg/5mL inj Anticonvulsants Anticonvulsants, AMANTADINE TAB 100MG amantadine 100mg cap Antiparkinson Antiparkinson, CYCLOBENZAPR TAB 5MG tizanidine tab, baclofen tab or a prescription generic oral NSAID, such as, ibuprofen, meloxicam, naproxen, nabumetone Skeletal Muscle Relaxants Skeletal Muscle Relaxants METHOCARBAM TAB 500MG tizanidine tab, baclofen tab or a prescription generic oral NSAID, such as, ibuprofen, meloxicam, naproxen, nabumetone Skeletal Muscle Relaxants Skeletal Muscle Relaxants METHOCARBAM TAB 750MG tizanidine tab, baclofen tab or a prescription generic oral NSAID, such as, ibuprofen, meloxicam, naproxen, nabumetone Skeletal Muscle Relaxants Skeletal Muscle Relaxants POT CHLORIDE CAP 10MEQ ER potassium chloride 10mEq tab Therapeutic Nutrients/ Minerals/ Electrolytes Electrolyte/Mineral Replacement Pg. 20 of 22

21 LIPOSYN III INJ 30% Not on formulary because does not meet the definition of a Part D drug under CMS regulations VIGAMOX DRO 0.5% LEVOBUNOLOL SOL 0.25% OP RESTASIS EMU 0.05% PATANOL SOL 0.1% OP CLINDAMYCIN SOL 1% fat emulsion 20%* *Please note, this formulary Therapeutic Nutrients/ for more information. Minerals/ Electrolytes ciprofloxacin solution, gentamicin solution, ofloxacin solution or Therapeutic Nutrients/ Minerals/ Electrolytes tobramycin solution Antibacterials Quinolones betaxolol 0.5%, carteolol 1%, levobunolol 0.5%, metipranolol 0.3%, timolol 0.25% or timolol 0.5% Ophthalmic Ophthalmic Antiglaucoma authorization check with your doctor Ophthalmic Ophthalmic, azelastine 0.05%, cromolyn sodium 4%, epinastine 0.05% or Pataday Ophthalmic erythromycin 2% solution, sulfacetamide 10% lotion or Ophthalmic Anti-allergy suspension Antibacterials Antibacterials, erythromycin 2% solution, sulfacetamide 10% lotion or suspension Antibacterials Antibacterials, CLINDAMAX GEL 1% erythromycin 2% solution, sulfacetamide 10% lotion or CLINDAMYCIN GEL 1% suspension Antibacterials Antibacterials, CARAC CRE 0.5% fluorouracil 5% cream Dermatological Dermatological Pg. 21 of 22

22 On formulary, quantity limit max of 90 patches per 30 LIDOCAINE PAD 5% may apply days Anesthetics Local Anesthetics ULESFIA LOT 5% malathion or permethrin Antiparasitics Pediculicides/Scabicides GLUCAGEN INJ 1MG Glucagen inj 1mg hypokit Blood Glucose Regulators Glycemic CELLCEPT SUS 200MG/ML mycophenolate mofetil suspension* *Please note, this formulary alternative or for more information. Immunological Immune Suppressants Pg. 22 of 22

Upper Peninsula Health Plan Advantage (HMO) (List of Covered Drugs)

Upper Peninsula Health Plan Advantage (HMO) (List of Covered Drugs) Analgesics Opioid Analgesics, Long-acting fentanyl 100 mcg/hr patch td72 morphine sulfate 30 mg tablet er Opioid Analgesics, Short-acting fentanyl citrate 200 mcg lozenge hd hydrocodone/acetaminophen 5

More information

CMI Marketplace 2015 (List of Covered Drugs)

CMI Marketplace 2015 (List of Covered Drugs) Analgesics Opioid Analgesics, Long-acting fentanyl 100 mcg/hr patch td72 fentanyl citrate 200 mcg lozenge hd morphine sulfate 30 mg tablet er oxymorphone hcl 7.5 mg tab er 12h Opioid Analgesics, Short-acting

More information

Aetna Better Health Illinois Premier Plan. November 2015 Formulary Updates. October 2015 Formulary Updates

Aetna Better Health Illinois Premier Plan. November 2015 Formulary Updates. October 2015 Formulary Updates Aetna Better Health Illinois Premier Plan November 2015 Formulary Updates desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg RIVASTIGMINE DIS 13.3/24; QL (30 patches/30 days) RIVASTIGMINE DIS 4.6MG/24;

More information

Medicare Part D 2016 Formulary Changes Service To Senior and OC Preferred

Medicare Part D 2016 Formulary Changes Service To Senior and OC Preferred Medicare Part D 2016 Formulary s Service To Senior and OC Preferred Inter Valley Health Plan may add or remove drugs from our formulary during the year. If we remove a drug from our formulary, add prior

More information

2018 Step Therapy Criteria

2018 Step Therapy Criteria 2018 Step Therapy Criteria ANGIOTENSIN RECEPTOR BLOCKERS... 2 ANTIDEPRESSANTS... 3 ANTIDEPRESSANTS, MISCELLANEOUS... 4 ANTIDEPRESSANTS, OTHER... 5 ANTIDIABETIC AGENTS... 6 ANTIGOUT AGENTS... 7 ANTIHYPERTENSIVE

More information

FLORIDA 2017 EHB BENCHMARK PLAN

FLORIDA 2017 EHB BENCHMARK PLAN FLORIDA EHB BENCHMARK PLAN SUMMARY INFORMATION Plan Type Issuer Name Product Name Small Group Market Blue Cross and Blue Shield of Florida BlueOptions Plan Name BlueOptions Supplemented Categories (Supplementary

More information

3 Tier Formulary Additions

3 Tier Formulary Additions 3 Tier Formulary Additions Drug Name Tier Category Management ACCU-CHECK GUIDE ME GLUCOSE METER 3 Diabetic Supplies Step Therapy applies pyridostigmine bromide 60mg/5ml syrup 1 Antimyasthenic Agents New

More information

Step Therapy Requirements

Step Therapy Requirements An Independent Licensee of the Blue Cross and Blue Shield Association Step Therapy Requirements Effective: 12/01/2017 Updated 11/2017 H0302_2_2014 CMS Accepted 05/05/2014 1 ABILIFY Abilify 10 mg tablet

More information

WellCare Signature (PDP) and WellCare Classic (PDP) Formulary Addendum

WellCare Signature (PDP) and WellCare Classic (PDP) Formulary Addendum WellCare Signature (PDP) and WellCare Classic (PDP) Formulary Addendum This is a listing of the changes that have occurred in our formulary. Please carefully review these changes and call WellCare if you

More information

PDP Classic Formulary Addendum

PDP Classic Formulary Addendum PDP Classic Formulary Addendum The following medications have been added to the WellCare formulary as of March 2009. Drug Name Therapeutic Class Drug Tier Requirements/Limits Changes Made acetazolamide

More information

Quarterly pharmacy formulary change notice

Quarterly pharmacy formulary change notice Quarterly pharmacy formulary change notice Provider update Summary: The formulary changes listed in the table below were reviewed and approved at our second quarter 2018, Pharmacy and Therapeutics Committee

More information

ASEBP and ARTA TARP Drugs and Reference Price by Categories

ASEBP and ARTA TARP Drugs and Reference Price by Categories ASEBP Pantoprazole Sodium 40 mg (generic) $0.2016 ASEBP Dexlansoprazole 30 mg Dexlansoprazole 60 mg Esomeprazole 10 mg Esomeprazole 20 mg Esomeprazole 40 mg Lansoprazole 15 mg Lansoprazole 30 mg Omeprazole

More information

ALLERGIC RHINITIS-NASAL

ALLERGIC RHINITIS-NASAL ALLERGIC RHINITIS-NASAL FLUNISOLIDE Patient needs to have paid claims for any one of the following Step 1 drugs: NasaCort OTC, fluticasone Rx, fluticasone OTC, Budesonide OTC. Prior to filling the Step

More information

Your prescription benefit updates Formulary Updates - Effective January 1, 2019

Your prescription benefit updates Formulary Updates - Effective January 1, 2019 Your prescription benefit updates Formulary Updates - Effective January 1, 2019 Medications are grouped by the conditions they treat. Each medication is placed in a tier that shows the amount you will

More information

Aetna Better Health of Illinois Medicaid Formulary Updates

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

More information

UPDATE WellCare s South Carolina

UPDATE WellCare s South Carolina September 3, 2015 UPDATE WellCare s South Carolina Preferred Drug List Dear Provider: At the September 3, 2015 WellCare Pharmacy & Therapeutics Committee meeting, it was decided that the following changes

More information

2017 Formulary (List of Covered Drugs)

2017 Formulary (List of Covered Drugs) 017 Formulary (List of Covered Drugs) Liberty Health Advantage Preferred Choice (HMO) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File

More information

Medicare Part D 2016 Formulary Changes Desert Preferred Choice

Medicare Part D 2016 Formulary Changes Desert Preferred Choice Medicare Part D 2016 Formulary s Desert Preferred Choice Inter Valley Health Plan may add or remove drugs from our formulary during the year. If we remove a drug from our formulary, add prior authorization,

More information

Network Health Insurance Corporation Upcoming Negative Changes to the Medicare Part D Formulary

Network Health Insurance Corporation Upcoming Negative Changes to the Medicare Part D Formulary Requesting an Exception to the Formulary You can ask Network Health Insurance Corporation to make an exception to our coverage rules. Generally, we will only approve your request for an exception if alternative

More information

Hundreds of Choices. More Savings Every Day. 8 and $ 12 Generics Also Available. Based on 30-day supply at commonly prescribed doses

Hundreds of Choices. More Savings Every Day. 8 and $ 12 Generics Also Available. Based on 30-day supply at commonly prescribed doses 4$ Hundreds of Choices. More Savings Every Day. $ 8 and $ 12 Generics Also Available. Based on 30-day supply at commonly prescribed doses EFF. DATE 09/2017 List subject to change ALLERGIES, COLD AND FLU

More information

FORMULARY Revised January 2019

FORMULARY Revised January 2019 MEDICATION STRENGTH NOTES ANTIMICROBIALS-ANTIBIOTICS AMOXICILLIN CAPS 500 MG AMOXICILLIN SUSP 125 MG/5 ML 250 MG/5 ML 400 MG/5 ML AMOXICILLIN CHEW 250 MG AMOXICILLIN AND CLAVULANIC ACID CAPS (AUGMENTIN)

More information

ALZHEIMER'S DRUGS. Details. Step 2: Exelon Patch 13.3 mg/24 hour transdermal Exelon Patch 4.6 mg/24 hr transdermal

ALZHEIMER'S DRUGS. Details. Step 2: Exelon Patch 13.3 mg/24 hour transdermal Exelon Patch 4.6 mg/24 hr transdermal ALZHEIMER'S DRUGS Products Affected Step 1: donepezil 10 mg disintegrating tablet donepezil 10 mg tablet donepezil 23 mg tablet donepezil 5 mg disintegrating tablet donepezil 5 mg tablet galantamine 12

More information

2013 Step Therapy (ST) Criteria

2013 Step Therapy (ST) Criteria 2013 Step Therapy (ST) Criteria Some drugs require step therapy pre-approval. This means that your doctor must have you first try a different drug to treat your medical condition before we will cover a

More information

Medicare Part D 2016 Formulary Changes Service To Senior and OC Preferred

Medicare Part D 2016 Formulary Changes Service To Senior and OC Preferred Medicare Part D 2016 Formulary s Service To Senior and OC Preferred Inter Valley Health Plan may add or remove drugs from our formulary during the year. If we remove a drug from our formulary, add prior

More information

Alprazolam 0.25mg, 0.5mg, 1mg tablets

Alprazolam 0.25mg, 0.5mg, 1mg tablets Presbyterian Senior Care (HMO) / Presbyterian MediCare PPO Quantity Limits Effective November 1, 2014 For the most recent list of drugs or other questions, please contact the Presbyterian Customer Service

More information

AETNA BETTER HEALTH January 2017 Formulary Change(s)

AETNA BETTER HEALTH January 2017 Formulary Change(s) AETNA BETTER HEALTH January 2017 Formulary Change(s) The following updates will be made to the Aetna Better Health of MI formulary on March 1, 2017 Drug Name, Strength, Dosage Form ALFUZOSIN HCL ER 10

More information

ARBS MEDICATION(S) SUBJECT TO STEP THERAPY DIOVAN HCT MG TAB, DIOVAN HCT MG TABLET

ARBS MEDICATION(S) SUBJECT TO STEP THERAPY DIOVAN HCT MG TAB, DIOVAN HCT MG TABLET ARBS DIOVAN HCT 160-12.5 MG TAB, DIOVAN HCT 80-12.5 MG TABLET 30-day trial of a Step 1 drug in the previous 120 days is required. Step 1 Drugs: Losartan, Losartan/HCTZ PAGE 1 LAST UPDATED 05/2016 BILE

More information

WellCare s South Carolina Preferred Drug List Update

WellCare s South Carolina Preferred Drug List Update WellCare s South Carolina Preferred Drug List Update This is a list of changes to our preferred drug list. These are a result of the latest WellCare Pharmacy & Therapeutics meeting held on 09/03/2015.

More information

2017 Step Therapy Criteria

2017 Step Therapy Criteria FRESENIUS TOTAL HEALTH 2017 Step Therapy Updated 07/01/2017. For more recent information or other questions, please contact Fresenius Total Health Customer Service at 1-855-598-6774 / TTY 1-844-209-9094.

More information

COLCRYS-PST. Products Affected Step 1: Mitigare 0.6 mg capsule. Details. Step 2: Colcrys 0.6 mg tablet

COLCRYS-PST. Products Affected Step 1: Mitigare 0.6 mg capsule. Details. Step 2: Colcrys 0.6 mg tablet COLCRYS-PST Mitigare 0.6 mg capsule Colcrys 0.6 mg tablet Criteria If the patient has tried one Step 1 product, authorization for a Step 2 product may be given. Exceptions can be made for a step 2 drug

More information

Step Therapy Requirements

Step Therapy Requirements An Independent Licensee of the Blue Cross and Blue Shield Association Step Therapy Requirements Effective: 05/01/2018 Updated 4/2018 H0302_2_2014 CMS Accepted 05/05/2014 1 BETA-BLOCKERS BYSTOLIC 10 MG

More information

Drugs That May Be Used by Certain Optometrists

Drugs That May Be Used by Certain Optometrists Drugs That May Be Used by Certain Optometrists Approved drugs. (a) Administration and prescription of pharmaceutical agents. Optometrists who are certified to prescribe and administer pharmaceutical agents

More information

Generic Drug List - Alphabetical

Generic Drug List - Alphabetical Generic Drug List - Alphabetical *** Individual pages can be printed by entering the page number in the Print Range field of the Print menu (Ctrl+P)*** Medication Name Category 30-Day 90-Day ACYCLOVIR

More information

FirstCarolinaCare Insurance Company Step Therapy Requirements

FirstCarolinaCare Insurance Company Step Therapy Requirements ANALGESICS, NARCOTICS KADIAN MORPHINE SULFATE ER PRIOR CLAIM FOR MORPHINE SULFATE SUSTAINED ACTION TABLET (MS CONTIN) WITHIN THE PAST 120 DAYS. ANTIBACTERIALS (EENT) BESIVANCE PRIOR CLAIM FOR CIPROFLOXACIN

More information

CONTENTS SECTION 1 SECTION

CONTENTS SECTION 1 SECTION CONTENTS SECTION 1 Foundations of Drug Therapy 1 CHAPTER 1 Introduction to Pharmacology 3 A Message to Students 3 Pharmacology and Drug Therapy 3 Understanding Grouping and Naming of Drugs 4 Prescription

More information

STEP THERAPY CRITERIA

STEP THERAPY CRITERIA STEP THERAPY This is a complete list of drugs that have written coverage determination policies. Drugs on this list do not indicate that this particular drug will be covered under your medical or prescription

More information

Riesbeck's Pharmacy Reward Club Generic Medication List October 2017

Riesbeck's Pharmacy Reward Club Generic Medication List October 2017 Allergy, Cold & Flu Antibiotic Treatments Arthritis & Pain Benzonatate 100mg cap 14 42 Diphenhydramine HCl Cap 50 MG 30 90 Diphenhydramine HCl Inj 50MG/ML 1 3 Diphenhydramine HCl Liquid 12.5 MG/5ML 720ml

More information

TN Cover Rx Tennessee CoverRx MAC Price Change List As of: 04/26/2018

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

More information

2016 Formulary (List of Covered Drugs) SUPERIOR HEALTH PLAN, INC. Superior HealthPlan Advantage (HMO SNP)

2016 Formulary (List of Covered Drugs) SUPERIOR HEALTH PLAN, INC. Superior HealthPlan Advantage (HMO SNP) SUPERIOR HEALTH PLAN, INC. Superior HealthPlan Advantage (HMO SNP) 2016 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. 00016423, Version

More information

STEP THERAPY CRITERIA

STEP THERAPY CRITERIA STEP THERAPY This is a complete list of drugs that have written coverage determination policies. Drugs on this list do not indicate that this particular drug will be covered under your medical or prescription

More information

COLCRYS-PST. Products Affected Step 1: Mitigare 0.6 mg capsule. Details. Step 2: Colcrys 0.6 mg tablet

COLCRYS-PST. Products Affected Step 1: Mitigare 0.6 mg capsule. Details. Step 2: Colcrys 0.6 mg tablet COLCRYS-PST Mitigare 0.6 mg capsule Colcrys 0.6 mg tablet Criteria If the patient has tried one Step 1 product, authorization for a Step 2 product may be given. Exceptions can be made for a step 2 drug

More information

Table A1: Fifty Most Often Repeated Oral Drug Product Shortages (35 ingredients), Canada,

Table A1: Fifty Most Often Repeated Oral Drug Product Shortages (35 ingredients), Canada, 1 Appendix Commentary 515 Appendix: Assessing Canada s Drug Shortage Problem Table A1: Fifty Most Often Repeated Oral Drug Product Shortages (35 ingredients), Canada, 2013 16 Drug Name Dosage Therapeutic

More information

Quarterly pharmacy formulary change notice

Quarterly pharmacy formulary change notice The formulary changes listed in the table below apply to all Anthem HealthKeepers Plus and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) members. These formulary changes,

More information

Riesbeck's Pharmacy Reward Club Generic Medication List February 2018 $4 30 Day Supply

Riesbeck's Pharmacy Reward Club Generic Medication List February 2018 $4 30 Day Supply Allergy, Cold & Flu Antibiotic Treatments Arthritis & Pain Benzonatate 100mg cap 14 42 Diphenhydramine HCl Cap 50 MG 30 90 Diphenhydramine HCl Inj 50MG/ML 1 3 Diphenhydramine HCl Liquid 12.5 MG/5ML 720ml

More information

DT Description Price Category Price change Percentage BNF 1.2 Mebeverine 135mg tablets (100) 759 M %

DT Description Price Category Price change Percentage BNF 1.2 Mebeverine 135mg tablets (100) 759 M % June 2016 On 13th May, the DH announced that there would be reductions to Category M prices from June until September. http://psnc.org.uk/our-news/contractor-notice-category-m-price-reduction/ This has

More information

PORTFOLIO Q October 2015 Availability of products is subject to patent restrictions in countries where applicable patents are in effect 1/6

PORTFOLIO Q October 2015 Availability of products is subject to patent restrictions in countries where applicable patents are in effect 1/6 Abiraterone Tablet 250 mg Q4 2016 Acetylsalicylic Acid Tablet GR 100 mg Available Aciclovir Cream 5% - 2 Grs Available Alendronic Acid Tablet 70 mg Available Amikacin Solution for injection 50 mg/ml; 125mg/ml;

More information

Oakwood Healthcare Low Cost Drug List for OHSCare & BCN

Oakwood Healthcare Low Cost Drug List for OHSCare & BCN Oakwood Healthcare Low Cost Drug List for OHSCare & BCN ACETAMINOPHEN-CODEINE ELIXIR Analgesic 240 720 ACYCLOVIR CAP 200MG Antiviral 30 90 AKTOB 0.3% EYE DROPS Miscellaneous 5 15 ALBUTEROL INH SOL 0.083%

More information

An Analysis of Exchange Plan Benefits for Certain Medicines

An Analysis of Exchange Plan Benefits for Certain Medicines An Analysis of Exchange Plan Benefits for Certain Medicines June 2014 In Seven of the Selected Classes, Over One-Fifth of Silver Plans Require Coinsurance of 40 Percent or More for All Drugs in Class 60%

More information

AETNA BETTER HEALTH January 2017 Formulary Change(s)

AETNA BETTER HEALTH January 2017 Formulary Change(s) AETNA BETTER HEALTH January 2017 Formulary Change(s) The following updates will be made to the Aetna Better Health of MI formulary on February 1, 2017 Drug Name, Strength, Dosage Form IVERMECTIN 3 MG TABLET

More information

2016 List of Covered Drugs (Formulary)

2016 List of Covered Drugs (Formulary) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. FOR RE INFORMATION, call Member Services at 1-8 from 8 a.m. to 8 p.m., seven days a week. TTY rs call 711. On weekends

More information

San Francisco Health Care Accountability Ordinance Minimum Standards Effective January 1, 2019

San Francisco Health Care Accountability Ordinance Minimum Standards Effective January 1, 2019 San Francisco Department of Public Health Barbara A. Garcia, MPA Director of Health City and County of San Francisco London N. Breed Mayor San Francisco Health Care Accountability Ordinance Standards Effective

More information

ANGIOTENSIN RECEPTOR BLOCKERS

ANGIOTENSIN RECEPTOR BLOCKERS Step Therapy 2014 2 Tier-Alameda Last Updated: 10/10/2014 ANGIOTENSIN RECEPTOR BLOCKERS Benicar Benicar Hct Diovan Valsartan Step 1: First line therapy should be irbesartan, irbesartan/hctz, losartan,

More information

Avoid paying too much for your prescriptions

Avoid paying too much for your prescriptions Quality health plans & benefits Healthier living Financial well-being Intelligent solutions 2017 Aetna Rx Step Program Medicine List Avoid paying too much for your prescriptions It s important to try to

More information

Riesbeck's Pharmacy Reward Club Generic Medication List September 2017

Riesbeck's Pharmacy Reward Club Generic Medication List September 2017 Drug Category Allergy, Cold & Flu Antibiotic Treatments Arthritis & Pain Riesbeck's Benzonatate 100mg cap 14 42 Diphenhydramine HCl Cap 50 MG 30 90 Diphenhydramine HCl Liquid 12.5 MG/5ML 720ml 2160ml Hydroxyzine

More information

WellCare Classic Formulary Addendum

WellCare Classic Formulary Addendum WellCare Classic Formulary Addendum The following medications have been added to the WellCare formulary as of September 2009. Drug Name Therapeutic Class Drug Tier Requirements/Limits Changes Made acetazolamide

More information

DT Description Price Category Price change

DT Description Price Category Price change Tariff T Watch October 2014 Readers are no doubt aware of this quarter's bad news for primary care prescribing allocations: NHS England has d the remuneration mechanism for community pharmacies gaining

More information

These medications will require preauthorization (PA) for HMSA Medicare Part D members.

These medications will require preauthorization (PA) for HMSA Medicare Part D members. Medicare Part D November 2014 CHANGES TO HMSA S MEDICARE FORMULARY As part of HMSA s ongoing efforts to provide our members a sustainable and affordable health plan option, it s necessary to make adjustments

More information

ATYPICAL ANTIPSYCHOTICS

ATYPICAL ANTIPSYCHOTICS Step Therapy CareOregon 2018 Last Updated: 07/27/2018 ATYPICAL ANTIPSYCHOTICS Fanapt Fanapt Titration Pack Paliperidone Er Vraylar The following criteria applies to members who newly start on the drug:

More information

Regence MedAdvantage + Rx Classic (PPO) and. Regence MedAdvantage + Rx Enhanced (PPO) 2015 Formulary. (List of Covered Drugs)

Regence MedAdvantage + Rx Classic (PPO) and. Regence MedAdvantage + Rx Enhanced (PPO) 2015 Formulary. (List of Covered Drugs) Regence MedAdvantage + Rx Classic (PPO) and Regence MedAdvantage + Rx Enhanced (PPO) 2015 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS WE COVER

More information

Allergy, Cough and Cold. Analgesic. Anti-Anxiety. Antibiotic

Allergy, Cough and Cold. Analgesic. Anti-Anxiety. Antibiotic For your convenience, this list is sorted by drug category. Drugs are categorized based on their most common use and may be included in more than one category. Drugs are not categorized by all of their

More information

PRESCRIPTION SAVINGS CLUB FLAT- PRICED GENERIC DRUG LIST (EMDEON) Effective August 20, 2014

PRESCRIPTION SAVINGS CLUB FLAT- PRICED GENERIC DRUG LIST (EMDEON) Effective August 20, 2014 PRESCRIPTION SAVINGS CLUB FLAT- PRICED GENERIC DRUG LIST (EMDEON) Effective August 20, 2014 The Prescription Savings Club provides its members with significant savings on prescription medications. The

More information

Alaska Medicaid 90 Day** Generic Prescription Medication List

Alaska Medicaid 90 Day** Generic Prescription Medication List 1 ACYCLOVIR 200 MG CAPSULE BUPROPION HCL 150 MG TAB ER 24H ACYCLOVIR 200 MG/5ML BUPROPION HCL 150 MG TABLET ER ACYCLOVIR 400 MG TABLET BUPROPION HCL 150 MG TABLET ER ACYCLOVIR 800 MG TABLET BUPROPION HCL

More information

DOSSIER LIST. tlo_seledyn.pdf :38:01 CMY K CM MY CY

DOSSIER LIST. tlo_seledyn.pdf :38:01 CMY K CM MY CY tlo_seledyn.pdf 1 22.08.2017 14:38:01 C M Y CM MY CY CMY K DOSSIER LIST tlo_seledyn.pdf 1 22.08.2017 14:38:01 PRODUCT NAME PHARMACEUTICAL FORM STRENGTH REFERENCE THERAPEUTIC CLASS ALIMENTARY TRACT & METABOLISM

More information

SmithRx Standard Formulary Step Therapy List

SmithRx Standard Formulary Step Therapy List SmithRx Standard Formulary Step Therapy List Revised: January 27, 2017 The following medications require prior use of at least one other medication for coverage. Please note that any plan-specific customizations

More information

OHIO MEDICAID PHARMACY COVERAGE

OHIO MEDICAID PHARMACY COVERAGE OHIO MEDICAID PHARMACY COVERAGE This information is intended for use by providers to help select the most appropriate cost-effective medication and formulation for their patients. Prescribers should utilize

More information

Step Therapy Requirements. Effective: 12/01/2016

Step Therapy Requirements. Effective: 12/01/2016 Effective: 12/01/2016 H2986_PD_049 Updated 11/2016 ALPHA 1-PROTEINASE INHIBITOR GLASSIA PRIOR CLAIM FOR ARALAST NP OR ZEMAIRA WITHIN THE PAST 120 DAYS. ANALGESICS, NARCOTICS KADIAN MORPHINE SULFATE ER

More information

2018 WPS MedicareRx Plan (PDP) Step Therapy

2018 WPS MedicareRx Plan (PDP) Step Therapy 2018 WPS MedicareRx Plan (PDP) Step Therapy In some cases, the WPS MedicareRx Plan (PDP) requires you to first try certain drugs to treat your medical condition before we will cover another drug for that

More information

2017 Formulary Changes Year to Date

2017 Formulary Changes Year to Date 2017 Formulary Changes Year to Date Health Choice Arizona may add or remove drugs from our formulary during the year. If we remove drugs from our formulary, add prior authorization, quantity limits and/or

More information

STEP THERAPY CRITERIA

STEP THERAPY CRITERIA STEP THERAPY This is a complete list of drugs that have written coverage determination policies. Drugs on this list do not indicate that this particular drug will be covered under your medical or prescription

More information

Drugs That Require Step Therapy (ST) Step Therapy Medications

Drugs That Require Step Therapy (ST) Step Therapy Medications Drugs That Require Step Therapy (ST) In some cases, BlueShield of Northeastern New York requires you to first try certain drugs to treat your medical condition before we will cover another drug for that

More information

Medicare Part D 2012 Formulary Changes Service To Senior and Total Fit

Medicare Part D 2012 Formulary Changes Service To Senior and Total Fit Medicare Part D 2012 Formulary s Service To Senior and Total Fit Inter Valley Health Plan may add or remove drugs from our formulary during the year. If we remove a drug from our formulary, add prior authorization,

More information

Acyclovir Ointment. Aetna Better Health Pennsylvania. Products Affected. acyclovir ointment 5 % external Details. Criteria

Acyclovir Ointment. Aetna Better Health Pennsylvania. Products Affected. acyclovir ointment 5 % external Details. Criteria Medications that require Step Therapy (ST) require trial and failure of preferred formulary agents prior to their authorization. If the prerequisite medications have been filled within the specified time

More information

PORTFOLIO Q June 2014 Availability of products is subject to patent restrictions in countries where applicable patents are in effect 1/5

PORTFOLIO Q June 2014 Availability of products is subject to patent restrictions in countries where applicable patents are in effect 1/5 Abiraterone Tablet 250 mg Q4 2015 Acetylsalicylic Acid Tablet GR 100 mg Available Aciclovir Cream 5% - 2 Grs Q4 2014 Alendronic Acid Tablet 70 mg Available Amisulpride Tablet 50 ; 100 ; 200 ; 400 mg Available

More information

$4 Prescription Program May 5, 2008

$4 Prescription Program May 5, 2008 Allergies & Cold and Flu Benzonatate 100mg 14 42 Ceron DM syrup 120ml 360ml Ceron drops* 30ml 90ml Dec-Chlorphen drops* 30ml 90ml Dec-Chlorphen DM syrup* 118ml 354ml Loratadine 10mg 30 90 Promethazine

More information

2014 Quantity Limits (QL) Criteria

2014 Quantity Limits (QL) Criteria 2014 Quantity Limits (QL) Criteria Certain drugs covered through your EmblemHealth Medicare HMO/PPO Medicare Plan are covered for only a limited quantity. We do this to ensure compliance with the US Food

More information

All Pharmacy and Prescribing Providers. Subject: State Maximum Allowable Cost (MAC) Updates

All Pharmacy and Prescribing Providers. Subject: State Maximum Allowable Cost (MAC) Updates INDIANA HEALTH COVERAGE PROGRAMS P R O V I D E R B U L L E T I N B T 2 0 0 7 1 2 M A Y 2 9, 2 0 0 7 To: All Pharmacy and Prescribing Providers Subject: State Maximum Allowable Cost (MAC) Updates Effective

More information

VNSNY CHOICE FIDA Complete Step Therapy Requirements. Effective: 01/01/2017

VNSNY CHOICE FIDA Complete Step Therapy Requirements. Effective: 01/01/2017 Effective: 01/01/2017 Updated 11/2016 ANTI-INFLAMMATORY AGENTS - GI DIPENTUM PRIOR CLAIM FOR BALSALAZIDE OR APRISO WITHIN THE PAST 120 DAYS. ANTICONVULSANTS APTIOM BANZEL FYCOMPA GABITRIL OXTELLAR XR POTIGA

More information

HNE Medicare Advantage Plan (HMO and HMO- POS) 2016 Formulary (List of Covered Drugs)

HNE Medicare Advantage Plan (HMO and HMO- POS) 2016 Formulary (List of Covered Drugs) HNE Medicare Advantage Plan (HMO and HMO- POS) 2016 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File

More information

Advanced Control Formulary Change Summary Report Effective

Advanced Control Formulary Change Summary Report Effective This report highlights all changes (additions, deletions, and removals) to the CVS Caremark Advanced Control Formulary. ADDITIONS: Brand Agents: Mepron (atovaquone) suspension Mydayis (amphetaminedextroamphetamine)

More information

Step Therapy Requirements. Effective: 03/01/2015

Step Therapy Requirements. Effective: 03/01/2015 Effective: 03/01/2015 Updated 02/2015 ANTI-INFLAMMATORY AGENTS - GI DIPENTUM PRIOR CLAIM FOR BALSALAZIDE OR APRISO WITHIN THE PAST 120 DAYS. ANTICONVULSANTS APTIOM BANZEL FYCOMPA OXTELLAR XR POTIGA QUDEXY

More information

ANTICHOLINERGIC BRONCHODILATORS ANTICHOLINERGIC BETA-AGONIST COMBO'S CORTICOSTEROID / BRONCHODILATOR COMBO'S NASAL STEROIDS LEUKOTRIENE MODIFIERS

ANTICHOLINERGIC BRONCHODILATORS ANTICHOLINERGIC BETA-AGONIST COMBO'S CORTICOSTEROID / BRONCHODILATOR COMBO'S NASAL STEROIDS LEUKOTRIENE MODIFIERS 1 of 5 ALLERGY / ASTHMA THERAPIES ANTIHISTAMINES, MINIMALLY SEDATING cetirizine fexofenadine loratadine ANTIHISTAMINE/DECONGESTANT COMBINATIONS cetirizine/pseudoephedrine fexofenadine/pseudoephedrine loratadine/pseudoephedrine

More information

Aetna Better Health of Michigan 1333 Gratiot Avenue, Suite 400 Detroit, MI AETNA BETTER HEALTH January 2017 Formulary Change(s)

Aetna Better Health of Michigan 1333 Gratiot Avenue, Suite 400 Detroit, MI AETNA BETTER HEALTH January 2017 Formulary Change(s) AETNA BETTER HEALTH January 2017 Formulary Change(s) The following updates will be made to the Aetna Better Health of MI formulary on July 1, 2017 ADAPALENE 0.1% CREAM ADAPALENE 0.1% GEL ATORVASTATIN 10

More information

Pharmacy Updates Summary

Pharmacy Updates Summary All of the following changes were reviewed and approved by the SFHP Pharmacy & Therapeutics (P&T) Committee on 04/15/2015 Effective date: 05/15/2015 Therapeutic Classes reviewed: Testosterone replacement

More information

COMMERCIAL APIs. S. No Molecule Name Therapeutic Category USDMF EDMF CEP IH

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

More information

Texas Vendor Drug Program. Formulary Drug Index File Layout. Layout effective: Jul. 2, 2018 Document update: Oct. 1, 2018

Texas Vendor Drug Program. Formulary Drug Index File Layout. Layout effective: Jul. 2, 2018 Document update: Oct. 1, 2018 Texas Vendor Drug Program Formulary Drug Index File Layout Layout effective: Jul. 2, 2018 Document update: Oct. 1, 2018 The Vendor Drug Program provides a weekly update of resource data available for download

More information

2015 Formulary (List of Covered Drugs)

2015 Formulary (List of Covered Drugs) HNE Medicare Advantage Plan (HMO and HMO-POS) 2015 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission

More information

Quarterly pharmacy formulary change notice

Quarterly pharmacy formulary change notice Provider Bulletin April 2018 This table is used by HealthKeepers, Inc. to indicate formulary changes applicable to all Anthem HealthKeepers Plus members. These changes were reviewed and approved at the

More information

Prescription Drug List Effective January 1, 2017 Oxford Connecticut Four-Tier

Prescription Drug List Effective January 1, 2017 Oxford Connecticut Four-Tier Your 2017 Prescription Drug List Effective January 1, 2017 Oxford Connecticut Four-Tier Please read: This document contains information about commonly prescribed medications. This Prescription Drug List

More information

Did you know that some medications can be harmful to people 65 years or older?

Did you know that some medications can be harmful to people 65 years or older? Did you know that some medications can be harmful to people 65 years or older? What s the risk? Some medications can be dangerous to people 65 years of age or older. As we age, our bodies change. These

More information

Ambetter 90-Day-Supply Maintenance Drug List

Ambetter 90-Day-Supply Maintenance Drug List Ambetter 90-Day-Supply Maintenance Drug List What is the Ambetter 90-Day-Supply Maintenance Drug List? Ambetter 90-Day-Supply Maintenance Drug List is a list of maintenance medications that are available

More information

UPDATE WellCare s South Carolina

UPDATE WellCare s South Carolina March 26, 2015 UPDATE WellCare s South Carolina Preferred Drug List Dear Provider: At the March 05, 2015 WellCare Pharmacy & Therapeutics Committee meeting, it was decided that the following changes will

More information

DRUG NAMING AND CLASSES

DRUG NAMING AND CLASSES DRUG NAMING AND CLASSES PROPRIETARY OR TRADEMARK NAME When a drug shows promise of being effective, the drug the sponsor will apply for a proprietary or trademark name. When a drug patent expires, other

More information

Notice of Mid-Year Changes to 2019 Paramount Enhanced Formulary

Notice of Mid-Year Changes to 2019 Paramount Enhanced Formulary Notice of Mid-Year s to 2019 Paramount Enhanced Formulary Paramount Elite (HMO) may immediately remove a brand name drug on our List if we are replacing it with a new generic drug that will appear on the

More information

2017 Formulary Addendum Notice of Change (Medicare Advantage Plans)

2017 Formulary Addendum Notice of Change (Medicare Advantage Plans) 207 Formulary Addendum Notice of Change (Medicare Advantage Plans) Easy Choice Health Plan Easy Choice Plus Plan (HMO) H5087-002, H5087-07 This is a listing of the changes that have occurred in our formulary.

More information

TennCare Program TN MAC Price Change List As of: 03/30/2017

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

More information

AVAILABLE DOSSIERS. Product name Pharmaceutical form Strength Reference Therapeutic class

AVAILABLE DOSSIERS. Product name Pharmaceutical form Strength Reference Therapeutic class DOSSIER LIST AVAILABLE DOSSIERS Product name Pharmaceutical form Strength Reference Therapeutic class ALIMENTARY TRACT & METABOLISM Esomeprazole sodium Omeprazole sodium injection / 40 mg Nexium / AstraZeneca

More information