2018 CareOregon Advantage Part D Formulary Changes
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1 2018 CareOregon Advantage Part D Formulary Changes Abbreviations: AGE = Age Restriction; PA = Prior Authorization Required; QL = Quantity Limit; ST = Step Therapy Required; LD = Limited Distribution; BvD = Must determine if covered under Parts B or D; = Limited to 1 Month Supplies; NA = Not Applicable EFFECTIVE DATE DRUG NAME STRENGTH DOSAGE FORM TYPE OF CHANGE 1/25/2018 Tamiflu 30mg Capsule 1/25/2018 Tamiflu 45mg and 75mg Capsule UTILIZATION RESTRICTIONS Tier 3 (Preferred Brand), QL 112 caps over a 365 day period Tier 3 (Preferred Brand), QL 56 caps over a 365 day period tenofovir 300mg Tier 6 (Specialty), triamcinolone acetonide 40mg Injection Tier 5 (Injectable), tigecycline 50mg IV Tier 6 (Specialty), PA, oseltamivir 6mg/mL Oral Suspension Tier 1 (Preferred Generic), QL 700mL over 365 days, 2mg; 5mg; 10mg; Tier 6 (Specialty), PA New Starts, QL 1 15mg; 20mg &; s Abilify MyCite tablet/day 30mg Juluca 50mg-25mg Tier 6 (Specialty), QL 1 tablet/day ArmonAir Respiclick 55mcg; 113mcg &; Inhaler Packs 232mcg Tier 3 (Preferred Brand) Ogiviri 420mg Injection Tier 6 (Specialty), PA New Starts Calquence 100mg Capsule Tier 6 (Specialty), PA New Starts, QL 2 capsules/day Alunbrig 180mg Tier 6 (Specialty), PA New Starts, QL 1 tablet/day, Tier 6 (Specialty), PA New Starts, QL 30 tablets over 180-day period Alunbrig Initiation Pack 90mg-180mg s Alunbrig 90mg-180mg Update Reduce QL to 1 tablet/day Endari buprenorphine 5gm Oral Powder Packet Tier 6 (Specialty), PA 5mcg/hr; 7.5mcg/hr; 10mcg/hr; 15mcg/hr &; 20mcg/hr Patch Tier 3 (Preferred Brand), PA, QL patches per day (4/28 days),
2 Benznidazole 12.5mg and 100mg Tier 3 (Preferred Brand), PA 2/27/2018 Qvar Redihaler 40mcg Inhaler Tier 3 (Preferred Brand), QL 1 inhaler per 60 day supply (0.177gm per day) 2/27/2018 Qvar Redihaler 80mcg Inhaler Tier 3 (Preferred Brand), QL 2 inhalers per 30 day supply (0.707gm per day) 3/1/2018 Mavyret mg Tier 6 (Specialty), PA, QL 3 tablets/day, 3/1/2018 Vosevi 400mg-100mg- Tier 6 (Specialty), PA, QL 1 tablet/day, 100mg 3/9/2018 Medroxyprogesterone 150mg/mL Prefilled Syringe Tier 5 (Injectable) 3/18/2018 Zepatier 50mg-100mg Delete Removed from formulary Biktavy 50mg-200mg- 25mg Bydureon Bcise 2mg/0.85mL Auto-injector Tier 6 (Specialty), QL 1 tablet/day, Tier 3 (Preferred Brand), QL 3.4mL/28 days (0.122mL per day) Fasenra 30mg/mL Prefilled Syringe Tier 6 (Specialty), PA, Fiasp Flextouch 100u/mL Pen Tier 4 (Non-preferred brand) Fiasp 100u/mL Vial Tier 3 (Preferred brand) Prolastin C 1000mg/20mL Vial Tier 6 (Specialty), PA, Qtern 10mg-5mg Tier 4 (Non-preferred brand), PA, QL 1 tab/day Shingrix 50mcg Vial Tier 3 (Preferred brand), PA for members under 50 years, QL 2 vials per lifetime Symfi Lo 400mg-300mg- 300mg Tier 6 (Specialty), QL 1 tablet/day, Symproic 0.2mg Tier 3 (Preferred Brand), PA, QL 1 tab/day Tracleer 32mg Tier 6 (Specialty), PA, QL 4 tabs/day, Trelegy Ellipta 100mcg-62.5mcg- Tier 3 (Preferred Brand), ST, QL 1 dose Inhaler 25mcg per day Zytiga 500mg Tier 6 (Specialty), PA New Starts, QL 2 tabs/day Xarelto 10mg Update
3 Victoza 18mg Pen Injector Update remove Trulicity 0.75mg and 1.5mg Pen Injector Update remove Bydureon 2mg Vial Update remove Bydureon 2mg Pen Injector Update remove Byetta 5mcg and 10mcg Pen Injector Update remove 5/1/2018 Abacavir 20mg/mL Oral Solution Tier 2 (Generic) 5/1/2018 Biktarvy 50mg-200mg- Tier 6 (Specialty) with QL 1/day and 25mg 5/1/2018 Efavirenz 200mg Capsule Tier 2 (Generic) 5/1/2018 Efavirenz 600mg Capsule Tier 6 (Specialty) with 5/1/2018 Ethinyl estradiollevonorgestrel (generic to LoSeasonique) 0.02mg-0.1mg x 84 and 0.01mg ethinyl estradiol x 7 Pack Tier 2 (Generic) 5/1/2018 Lansoprazole ODT 15mg and 30mg s Tier 2 (Generic), PA and QL 1 tablet per day Cimduo 300mg-300mg Tier 6 (Specialty) with QL 1/day and Prevymis 240mg and 480mg Tier 6 (Specialty) with PA, QL 1/day and Prevymis 240mg/12mL and Tier 6 (Specialty) with PA and Injection 480mg/24mL Symdeko 150mg-100mg and Tier 6 (Specialty) with PA, QL 2/day and Kit 150mg only Symfi 600mg-300mg- Tier 6 (Specialty) with QL 1/day and 300mg 2.5mg; 5mg; 7.5mg; 10mg; Update Remove QL Olanzapine 15mg and; 20mg Olanzapine 5mg; 10mg; 15mg and; 20mg ODT Update Remove QL Ilaris 150mg/mL Injection Solution Tier 6 (Specialty) with PA and
4 Rubraca 250mg Tier 6 (Specialty) with PA New Starts, QL 4/day and 7/1/2018 Zenpep 42000u-32000u u DR Capsule Tier 3 (Preferred Brand) 7/1/2018 Tasigna 50mg Capsule Tier 6 (Specialty) with PA New Starts and 8/1/2018 Ciprofloxacin 2mg/mL Otic Solution Tier 4 (Non-preferred brand) 7/1/2018 Syeda 28 Day 3mg; 0.03mg Tier 2 (Generic) 7/1/ mg-0.18mg- Tri-Vylibra 28 Day 0.215mg- 0.25mg Tier 1 (Preferred Generic) 7/1/2018 Vylibra 28 Day 0.035mg; 0.25mg Tier 1 (Preferred Generic) 7/1/2018 Toujeo 3mL Penn Injector 300u/mL Injection Tier 4 (Non-preferred Brand) 7/1/2018 Fiasp 3mL Penn Injector 100u/mL Injection Tier 4 (Non-preferred Brand) 7/1/2018 Methylphenidate 10mg ER Capsule Tier 2 (Generic), QL 1 per day, and 8/1/2018 Colesevelam HCl 625mg Tier 2 (Generic) with PA 8/1/2018 Tri-Mili 28 Day 0.035mg-0.18mg mg- 0.25mg Tier 1 (Preferred Generic) 8/1/2018 Estarylla 28 Day 0.035mg-0.25mg Tier 1 (Preferred Generic) 8/1/2018 Mili 28 Day 0.035mg-0.25mg Tier 1 (Preferred Generic) 8/1/2018 Norvir 100mg Powder Packet Tier 3 (Preferred Brand) 8/1/2018 Aimovig 1-pack 70mg/mL Injection Tier 5 (Injectable), PA, QL 1mL per 30 days and 8/1/2018 Aimovig 2-pack 70mg/mL Injection Tier 5 (Injectable), PA, QL 2mL per 30 days 8/1/2018 Humira PFS kit (2 Pack) 10mg/0.1mL Injection Tier 6 (Specialty), PA, QL 2 syringes per 28 days and 8/1/2018 Humira Auto-injector kit (2 Tier 6 (Specialty), PA, QL 6 syringes per 40mg/0.4mL Injection pack) 28 days and 8/1/2018 Humira PFS kit (2 pack) 40mg/0.4mL Injection Tier 6 (Specialty), PA, QL 6 syringes per 28 days and 8/1/2018 Humira Pediatric Crohn s Starter Kit (2 Pack) 80mg/0.8ml PFS plus 40mg/0.4ml PFS Injection Tier 6 (Specialty), PA, QL 2 syringes in a 180 day period and
5 8/1/2018 Humira Pediatric Crohn s Tier 6 (Specialty), PA, QL 3 syringes in a 80mg/0.8ml PFS Injection Starter Kit (3 Pack) 180 day period and 8/1/2018 Tavalisse 100mg and 150mg Tier 6 (Specialty), PA for New Starts, QL 2 tablets per day and 8/1/2018 Yonsa 125mg Tier 6 (Specialty), PA for New Starts, QL 4 tablets per day and 9/1/2018 Miglustat 100mg Capsule Tier 6 (Specialty), PA and 9/1/2018 Gabitril 12mg and 16mg s Delete Generics now on formulary 9/1/2018 Norvir 100mg Delete Generic now on formulary 9/1/2018 Sustiva 600mg Delete Generic now on formulary 9/1/2018 Safyral mg Delete Generic now on formulary 9/1/2018 Zavesca 100mg Capsule Delete Generic now on formulary 9/1/2018 Syprine 250mg Capsule Delete Generic now on formulary 9/25//2018 Braftovi 50mg Capsule Tier 6 (Specialty), PA for New Starts, QL 4 capsules per day and 9/25/2018 Braftovi 75mg Capsule Tier 6 (Specialty), PA for New Starts, QL 6 capsules per day and 9/25/2018 Mektovi 15mg Tier 6 (Specialty), PA for New Starts, QL 6 tablets per day and 10/1/2018 Humira 20mg/0.2mL Syringe Tier 6 (Specialty), PA, QL 2 syringes per 28 days, 10/1/2018 Jynarque Paks (14) 45mg-15mg; 60mg- 30mg; 90mg- 30mg; 10/1/2018 Doptelet 20mg 10/12018 Lucemyra 0.18mg 10/1/2018 Symtuza 800mg-150mg- 200mg-10mg 10/1/2018 Lenvima Dosepack 4mg Capsule 10/1/2018 Lenvima Dosepack 12mg Capsule 10/1/2018 Gilenya 0.25mg Capsule 9/27/2018 Nuplazid 34mg Capsule Tier 6 (Specialty), PA, QL 2 tablets per day, Tier 6 (Specialty), PA, QL 3 tablets per day with 5 days max per Rx and Tier 6 (Specialty), PA, QL 16 tablets per day with 16 days max per Rx and Tier 6 (Specialty), PA, QL 1 tablet/day, capsule/day and Tier 6 (Specialty), PA for New Starts, QL 3 capsules/day and Tier 6 (Specialty), PA, QL 1 capsule/day, capsule/day and
6 9/27/2018 Nuplazid 10mg tablet/day and 10/1/2018 Palynziq 2.5mg and 10mg Syringe Tier 6 (Specialty), PA, QL 1 per day, 10/1/2018 Palynziq 2.5mg and 10mg Syringe Tier 6 (Specialty), PA, QL 2 per day, 10/1/2018 Retacrit 2,000u; 3,000u; 4,000u; 10,000u Vial Tier 5 (Injectable) with PA and; 40,000u 10/1/2018 Fulphila 6mg/0.6mL Syringe Tier 6 (Specialty) with PA & 10/1/2018 Tibsovo 250mg Tier 6 (Specialty) with PA for New Starts, QL 2 per day, 1 Copiktra 15mg and 25mg Capsule Tier 6 (Specialty) with PA for New Starts, 1 Delstrigo 100mg-300mg- 300mg 1 Galafold 123mg Capsule QL 2 per day, Tier 6 (Specialty) with QL 1/day and Tier 6 (Specialty), PA, QL 15 caps/30 days and 1 Libtayo 350mg/7mL Vial Tier 6 (Specialty), PA for New Starts, 1 Lokelma 5gm and 10gm Packet Tier 6 (Specialty), PA, QL 3 packs/day, 1 Lumoxiti 1mg Vial Tier 6 (Specialty), PA for New Starts, 1 Orilissa 150mg Tier 6 (Specialty), PA, QL 1 per day, 1 Orilissa 200mg Tier 6 (Specialty), PA, QL 2 per day, 1 Pifeltro 100mg Tier 6 (Specialty), QL 1 per day, 1 Talzenna 0.25mg Capsule Tier 6 (Specialty), PA for New Starts, QL 3 per day, 1 Talzenna 1mg Capsule per day, 1 Vizimpro 15mg; 30mg and; 40mg per day,
7
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