Health Partners Medicare Special (2017) Updates
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- Wilfred Hutchinson
- 5 years ago
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1 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 NAMZARIC EMEND allopurinol sodium memantine hcl/donepezil hcl memantine hcl/donepezil hcl memantine hcl/donepezil hcl allopurinol sodium TREXIMET sumatriptan succinate/naproxen sodium YONDELIS epirubicin hcl RUBRACA RUBRACA KYPROLIS KYPROLIS LARTRUVO pramipexole er trabectedin epirubicin hcl rucaparib camsylate rucaparib camsylate carfilzomib carfilzomib olaratumab pramipexole di-hcl PAGE 1 UPDATED 04/2017
2 Effective Date Brand Name Generic Name Type of Change Previous Value New Value rasagiline mesylate rasagiline mesylate quetiapine fumarate er quetiapine fumarate er quetiapine fumarate er quetiapine fumarate er quetiapine fumarate er rasagiline mesylate rasagiline mesylate quetiapine fumarate quetiapine fumarate quetiapine fumarate quetiapine fumarate quetiapine fumarate valganciclovir hcl valganciclovir hcl abacavirlamivudine oseltamivir phosphate oseltamivir phosphate oseltamivir phosphate abacavir sulfate/lamivudine oseltamivir phosphate oseltamivir phosphate oseltamivir phosphate INVOKAMET XR canagliflozin/metformin hcl INVOKAMET XR canagliflozin/metformin hcl INVOKAMET XR canagliflozin/metformin hcl INVOKAMET XR canagliflozin/metformin hcl BASAGLAR insulin glargine,human KWIKPEN U-100 recombinant analog PAGE 2 UPDATED 04/2017
3 Effective Date Brand Name AFREZZA AFREZZA olmesartan Generic Name insulin regular, human insulin regular, human olmesartan Type of Change Previous Value New Value QBRELIS lisinopril REPATHA PUSHTRONEX nitroglycerin nitroglycerin nitroglycerin evolocumab nitroglycerin nitroglycerin nitroglycerin methylphenidate methylphenidate hcl hcl cd,methylphenida te hcl er methylphenidate methylphenidate hcl hcl cd,methylphenida te hcl er GONITRO nitroglycerin ALA-CORT MICORT-HC clindamycin phos-tretinoin PERTZYE PANCREAZE OCALIVA OCALIVA RELISTOR hydrocortisone hydrocortisone acetate clindamycin phosphate/tretinoin lipase/protease/amylase lipase/protease/amylase obeticholic acid obeticholic acid methylnaltrexone bromide PAGE 3 UPDATED 04/2017
4 Effective Date Brand Name Generic Name Type of Change Previous Value New Value MYTESI crofelemer flurandrenolide prednisone flurandrenolide prednisone drospirenone-eth drospirenone/ethinyl estra-levomef /levomefolate calcium norethin-eth norethindrone-ethinyl estra-ferrous fum /ferrous fumarate CAMRESE LO ALYACEN LARISSIA FEMYNOR AMABELZ AMABELZ levonorgestrel/ethinyl and ethinyl norethindrone-ethinyl levonorgestrel-ethinyl norgestimate-ethinyl /norethindrone acetate /norethindrone acetate ethynodiol-ethinyl ethynodiol diacetate-ethinyl INFLECTRA ORENCIA CLICKJECT mycophenolate mofetil infliximab-dyyb abatacept mycophenolate mofetil hcl GAMASTAN S-D immune globulin,gamma(igg)/glycine PAGE 4 UPDATED 04/2017
5 Effective Date Brand Name Generic Name Type of Change Previous Value New Value GAMMAGARD S- immune D globulin,gamm(igg)/glycine/g lucose/iga 0 to 50 mcg/ml GAMMAGARD S- immune D globulin,gamm(igg)/glycine/g lucose/iga 0 to 50 mcg/ml PEDIARIX KINRIX mesalamine EXONDYS 51 EXONDYS 51 levalbuterol tartrate hfa ADRENACLICK ADRENACLICK ORKAMBI SPS daptomycin nilutamide olmesartan olmesartan hep b virus,rcmb/dipth,pertus(acell ),tet,polio vaccine/pf diphtheria, pertussis(acell),tetanus,polio vaccine/pf mesalamine eteplirsen eteplirsen levalbuterol tartrate epinephrine epinephrine lumacaftor/ivacaftor sodium polystyrene sulfonate/sorbitol solution daptomycin nilutamide olmesartan olmesartan PAGE 5 UPDATED 04/2017
6 Effective Date Brand Name Generic Name Type of Change Previous Value New Value olmesartanamlodipine-hctz olmesartan /amlodipine besylate/hydrochlorothiazide olmesartan- olmesartan hydrochlorothiazi /hydrochlorothiazi de de olmesartan- olmesartan hydrochlorothiazi /hydrochlorothiazi de de olmesartan- olmesartan hydrochlorothiazi /hydrochlorothiazi de de amlodipine- amlodipine olmesartan besylate/olmesartan olmesartanamlodipine-hctz olmesartanamlodipine-hctz olmesartanamlodipine-hctz olmesartanamlodipine-hctz amlodipineolmesartan amlodipineolmesartan olmesartan /amlodipine besylate/hydrochlorothiazide olmesartan /amlodipine besylate/hydrochlorothiazide olmesartan /amlodipine besylate/hydrochlorothiazide olmesartan /amlodipine besylate/hydrochlorothiazide amlodipine besylate/olmesartan amlodipine besylate/olmesartan PAGE 6 UPDATED 04/2017
7 Effective Date Brand Name Generic Name Type of Change Previous Value New Value amlodipineolmesartan amlodipine besylate/olmesartan ZARAH ethinyl /drospirenone AMETHIA LO levonorgestrel/ethinyl and ethinyl norethindron- norethindrone acetate- ethinyl ethinyl YUVAFEM norgestimateethinyl CAZIANT OTREXUP IMOGAM RABIES-HT norgestimate-ethinyl desogestrel-ethinyl methotrexate/pf rabies immune globulin/pf ethacrynic acid ezetimibe omeprazolesodium bicarbonate omeprazolesodium bicarbonate ethacrynic acid ezetimibe omeprazole/sodium bicarbonate omeprazole/sodium bicarbonate REMOVE FROM FORMULARY REMOVE FROM FORMULARY prednisone prednisone CHANGE TIER BIVIGAM immune globulin,gamm(igg)/glycine/i ga greater than 50 mcg/ml PAGE 7 UPDATED 04/2017
8 Effective Date Brand Name Generic Name Type of Change Previous Value New Value abacavirlamivudine abacavir sulfate/lamivudine ADD UM: QUANTITY 1 / 1 DAYS ELIQUIS apixaban CHANGE UM: QUANTITY oxybutynin chloride er KYPROLIS KYPROLIS YONDELIS RUBRACA RUBRACA LARTRUVO nilutamide ORENCIA CLICKJECT oxybutynin chloride carfilzomib carfilzomib trabectedin rucaparib camsylate rucaparib camsylate olaratumab nilutamide abatacept GAMMAGARD S- immune D globulin,gamm(igg)/glycine/g lucose/iga 0 to 50 mcg/ml CHANGE UM: QUANTITY 2 / 1 DAYS 1 / 1 DAYS 74 / 30 DAYS 2 / 1 DAYS GAMMAGARD S- immune D globulin,gamm(igg)/glycine/g lucose/iga 0 to 50 mcg/ml ORKAMBI EXONDYS 51 lumacaftor/ivacaftor eteplirsen PAGE 8 UPDATED 04/2017
9 Effective Date Brand Name Generic Name Type of Change Previous Value New Value EXONDYS 51 eteplirsen INFLECTRA OCALIVA OCALIVA GENTAK hydrocortisone hydrocortisone ACTEMRA infliximab-dyyb obeticholic acid obeticholic acid gentamicin sulfate hydrocortisone hydrocortisone tocilizumab ACTEMRA tocilizumab PAGE 9 UPDATED 04/2017
10 March/April 2017 Effective Date 04/01/ /01/ /01/ /01/ /01/ /01/2017 Brand Name SF 5000 PLUS metformin hcl er ZERIT Generic Name sodium fluoride metformin hcl stavudine lopinavir-ritonavir lopinavir/ritonavir norgestimateethinyl norgestimate-ethinyl Type of Change Previous Value New Value azithromycin azithromycin REMOVE UM: QUANTITY SOLU-MEDROL methylprednisolone sodium succinate/pf,methylprednisol one sodium succinate oxiconazole nitrate amlodipine besylate oxiconazole nitrate amlodipine besylate CHANGE TIER 10 / 30 DAYS CHANGE UM: QUANTITY 2 / 1 DAYS 3 / 1 DAYS PAGE 10 UPDATED 04/2017
11 May 2017 Effective Date cyclopentolate hcl Brand Name Generic Name Type of Change Previous Value JOLIVETTE norethindrone cyclopentolate hcl desvenlafaxine succinate er desvenlafaxine succinate er desvenlafaxine succinate er butalbital compoundcodeine,asabutalb-caffeinecodeine NAMZARIC NAMZARIC SELZENTRY SELZENTRY cyclopentolate hcl cyclopentolate hcl desvenlafaxine succinate desvenlafaxine succinate desvenlafaxine succinate codeine phosphate/butalbital/aspirin/ caffeine memantine hcl/donepezil hcl memantine hcl/donepezil hcl maraviroc CHANGE TIER calcium acetate calcium acetate LINZESS linaclotide maraviroc methylphenidate methylphenidate hcl la New Value PAGE 11 UPDATED 04/2017
12 Effective Date Brand Name flurandrenolide prednisolone sodium phosphate prednisolone sodium phosphate Generic Name Type of Change Previous Value New Value flurandrenolide prednisolone sod phosphate prednisolone sod phosphate LINZESS linaclotide ADD UM: QUANTITY 1 / 1 DAYS methylphenidate methylphenidate hcl er,methylphenida te la methylphenidate methylphenidate hcl er,methylphenida te la PAGE 12 UPDATED 04/2017
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