HAP/Midwest Health Advantage MI Health Link (MMP) Updates
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- Colin Henderson
- 5 years ago
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1 January, /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 01/01/2018 KIONEX sodium polystyrene sulfonate/sorbitol solution PAGE 1 UPDATED 11/2018
2 March, /01/2018 eletriptan hbr eletriptan hydrobromide 03/01/2018 eletriptan hbr eletriptan hydrobromide ADD UM: QUANTITY 12 / 30 OVER 03/01/ /01/2018 fosamprenavir calcium 03/01/2018 lanthanum carbonate 03/01/2018 lanthanum carbonate 03/01/2018 lanthanum carbonate fosamprenavir calcium lanthanum carbonate lanthanum carbonate lanthanum carbonate 03/01/2018 meropenem meropenem 03/01/2018 mesalamine mesalamine 03/01/2018 moxifloxacin moxifloxacin hcl 03/01/2018 oseltamivir phosphate 03/01/2018 oseltamivir phosphate oseltamivir phosphate oseltamivir phosphate ADD UM: QUANTITY 720 / 365 OVER 03/01/2018 oxaliplatin oxaliplatin 03/01/2018 paroxetine mesylate 03/01/2018 paroxetine mesylate 03/01/2018 piperacillintazobactam paroxetine mesylate ADD UM: QUANTITY 30 / 30 DAYS paroxetine mesylate piperacillin sodium/tazobactam sodium PAGE 2 UPDATED 11/2018
3 03/01/2018 peg electrolyte 03/01/2018 potassium chloride peg 3350/sod sulf/sod bicarb/sod chloride/potassium chloride potassium chloride 03/01/2018 prasugrel hcl prasugrel hcl 03/01/2018 prasugrel hcl prasugrel hcl 03/01/2018 sevelamer carbonate sevelamer carbonate 03/01/2018 vigabatrin vigabatrin 03/01/2018 isibloom desogestrel-ethinyl 03/01/2018 desogestrelethinyl 03/01/2018 ethynodiol-ethinyl 03/01/2018 norgestimateethinyl 03/01/2018 levonorg-eth estrad eth estrad 03/01/2018 levonorg-eth estrad eth estrad desogestrel-ethinyl ethynodiol diacetate-ethinyl norgestimate-ethinyl levonorgestrel/ethinyl and ethinyl levonorgestrel/ethinyl and ethinyl 03/01/2018 ADACEL TDAP diphtheria,pertussis(acellular ),tetanus vaccine/pf ADD UM: QUANTITY 91 / 91 DAYS 03/01/2018 HAVRIX hepatitis a virus vaccine/pf 03/01/2018 VAQTA hepatitis a virus vaccine/pf 03/01/2018 HUMALOG JUNIOR KWIKPEN insulin lispro PAGE 3 UPDATED 11/2018
4 03/01/2018 BYDUREON BCISE 03/01/2018 BYDUREON BCISE exenatide microspheres ADD UM: QUANTITY 3.4 / 28 DAYS exenatide microspheres 03/01/2018 BENLYSTA belimumab 03/01/2018 BENLYSTA belimumab 03/01/2018 FASENRA benralizumab 03/01/2018 TREMFYA guselkumab 03/01/2018 HAVRIX hepatitis a virus vaccine/pf 03/01/2018 TWINRIX hepatitis a virus and hepatitis b virus vaccine/pf 03/01/2018 VAQTA hepatitis a virus vaccine/pf 03/01/2018 OPDIVO nivolumab 03/01/2018 RADICAVA edaravone 03/01/2018 PREVYMIS letermovir 03/01/2018 VENTOLIN HFA albuterol sulfate 03/01/2018 VENTOLIN HFA albuterol sulfate ADD UM: QUANTITY 48 / 30 DAYS 03/01/2018 GOCOVRI amantadine hcl 03/01/2018 GOCOVRI amantadine hcl 03/01/2018 RAYALDEE calcifediol 03/01/2018 PREVYMIS letermovir 03/01/2018 LUPRON DEPOT-PED leuprolide acetate CHANGE UM: QUANTITY 1 / 112 days 1 / 84 OVER 03/01/2018 TRISENOX arsenic trioxide 03/01/2018 VERZENIO abemaciclib 03/01/2018 VERZENIO abemaciclib ADD UM: QUANTITY 60 / 30 DAYS PAGE 4 UPDATED 11/2018
5 03/01/2018 VERZENIO abemaciclib ADD UM: QUANTITY 60 / 30 DAYS 03/01/2018 VERZENIO abemaciclib 03/01/2018 VERZENIO abemaciclib ADD UM: QUANTITY 60 / 30 DAYS 03/01/2018 VERZENIO abemaciclib 03/01/2018 VERZENIO abemaciclib 03/01/2018 VERZENIO abemaciclib ADD UM: QUANTITY 60 / 30 DAYS 03/01/2018 CALQUENCE acalabrutinib ADD UM: QUANTITY 60 / 30 DAYS 03/01/2018 CALQUENCE acalabrutinib 03/01/2018 KADCYLA ado-trastuzumab emtansine 03/01/2018 ZENPEP lipase/protease/amylase 03/01/2018 TREANDA bendamustine hcl 03/01/2018 BOSULIF bosutinib 03/01/2018 PROLENSA bromfenac sodium 03/01/2018 PROLENSA bromfenac sodium ADD UM: QUANTITY 12 / 365 OVER 03/01/2018 NOVAREL chorionic gonadotropin, human 03/01/2018 clindacin p clindamycin phosphate 03/01/2018 ALIQOPA copanlisib di-hcl 03/01/2018 VYXEOS daunorubicin/cytarabine liposomal 03/01/2018 BAXDELA delafloxacin meglumine 03/01/2018 BAXDELA delafloxacin meglumine 03/01/2018 JULUCA dolutegravir sodium/rilpivirine hcl 03/01/2018 JULUCA dolutegravir sodium/rilpivirine hcl ADD UM: QUANTITY 30 / 30 DAYS PAGE 5 UPDATED 11/2018
6 03/01/2018 GLYXAMBI empagliflozin/linagliptin 03/01/2018 GLYXAMBI empagliflozin/linagliptin ADD UM: QUANTITY 30 / 30 DAYS 03/01/2018 GLYXAMBI empagliflozin/linagliptin 03/01/2018 GLYXAMBI empagliflozin/linagliptin ADD UM: QUANTITY 30 / 30 DAYS 03/01/2018 IDHIFA enasidenib mesylate 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 03/01/2018 profeno fenoprofen calcium 03/01/2018 MYLOTARG gemtuzumab ozogamicin 03/01/2018 MAVYRET glecaprevir/pibrentasvir ADD UM: QUANTITY 336 / 365 OVER 03/01/2018 MAVYRET glecaprevir/pibrentasvir 03/01/2018 RENFLEXIS infliximab-abda 03/01/2018 amnesteem isotretinoin 03/01/2018 amnesteem isotretinoin 03/01/2018 amnesteem isotretinoin 03/01/2018 PREVYMIS letermovir 03/01/2018 PREVYMIS letermovir 03/01/2018 XIIDRA lifitegrast ADD UM: QUANTITY 60 / 30 DAYS 03/01/2018 XIIDRA lifitegrast 03/01/2018 VABOMERE meropenem/vaborbactam 03/01/2018 XATMEP methotrexate 03/01/2018 NEVANAC nepafenac ADD UM: QUANTITY 6 / 30 OVER PAGE 6 UPDATED 11/2018
7 03/01/2018 NEVANAC nepafenac 03/01/2018 NERLYNX neratinib maleate ADD UM: QUANTITY 180 / 30 DAYS 03/01/2018 NERLYNX neratinib maleate 03/01/2018 NYMALIZE nimodipine 03/01/2018 LYNPARZA olaparib 03/01/2018 LYNPARZA olaparib 03/01/2018 PROAIR HFA albuterol sulfate CHANGE UM: QUANTITY 17 / 30 days 17 / 30 DAYS 03/01/2018 TAMIFLU oseltamivir phosphate 03/01/2018 TAMIFLU oseltamivir phosphate ADD UM: QUANTITY 112 / 365 OVER 03/01/2018 TAMIFLU oseltamivir phosphate 03/01/2018 TAMIFLU oseltamivir phosphate ADD UM: QUANTITY 60 / 365 OVER 03/01/2018 TAMIFLU oseltamivir phosphate 03/01/2018 TAMIFLU oseltamivir phosphate ADD UM: QUANTITY 110 / 365 OVER 03/01/2018 klor-con potassium chloride 03/01/2018 VOSEVI sofosbuvir/velpatasvir/voxila previr 03/01/2018 VOSEVI sofosbuvir/velpatasvir/voxila previr ADD UM: QUANTITY 84 / 365 OVER 03/01/2018 SYNDROS dronabinol ADD UM: QUANTITY 120 / 30 DAYS 03/01/2018 SYNDROS dronabinol 03/01/2018 XURIDEN uridine triacetate ADD UM: QUANTITY 120 / 30 DAYS 03/01/2018 XURIDEN uridine triacetate 03/01/2018 INGREZZA valbenazine tosylate 03/01/2018 INGREZZA valbenazine tosylate ADD UM: QUANTITY 30 / 30 DAYS PAGE 7 UPDATED 11/2018
8 03/01/2018 glatiramer acetate 03/01/2018 glatiramer acetate 03/01/2018 glatiramer acetate 03/01/2018 glatiramer acetate 03/01/2018 haloperidol decanoate glatiramer acetate ADD UM: QUANTITY 30 / 30 DAYS glatiramer acetate glatiramer acetate ADD UM: QUANTITY 12 / 28 DAYS glatiramer acetate haloperidol decanoate 03/01/2018 morphine sulfate morphine sulfate 03/01/2018 methotrexate methotrexate sodium 03/01/2018 carvedilol er carvedilol phosphate 03/01/2018 timolol maleate timolol maleate 03/01/2018 methylphenidate la 03/01/2018 methylphenidate la 03/01/2018 methylphenidate er methylphenidate hcl methylphenidate hcl ADD UM: QUANTITY 30 / 30 DAYS methylphenidate hcl CHANGE UM: QUANTITY 30 / 30 days 30 / 30 DAYS 03/01/2018 testosterone testosterone 03/01/2018 scopolamine scopolamine 03/01/2018 adapalenebenzoyl peroxide adapalene/benzoyl peroxide 03/01/2018 aripiprazole aripiprazole ADD UM: QUANTITY 750 / 30 DAYS 03/01/2018 aripiprazole aripiprazole 03/01/2018 bortezomib bortezomib PAGE 8 UPDATED 11/2018
9 03/01/2018 caspofungin acetate 03/01/2018 caspofungin acetate caspofungin acetate caspofungin acetate 03/01/2018 dactinomycin dactinomycin 03/01/2018 dapsone dapsone 03/01/2018 doxycycline hyclate 03/01/2018 doxycycline hyclate doxycycline hyclate doxycycline hyclate 03/01/2018 efavirenz efavirenz 03/01/2018 eletriptan hbr eletriptan hydrobromide ADD UM: QUANTITY 12 / 30 OVER 03/01/2018 eletriptan hbr eletriptan hydrobromide 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 UM: QUANTITY 60 / 30 days 60 / 30 DAYS 03/01/2018 SHINGRIX varicella-zoster virus glycoprotein e,rec/as01b adjuvant/pf PAGE 9 UPDATED 11/2018
10 April, /01/2018 altavera levonorgestrel-ethinyl 04/01/2018 kurvelo levonorgestrel-ethinyl 04/01/2018 enskyce desogestrel-ethinyl 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 04/01/2018 levetiracetam er,roweepra xr levetiracetam CHANGE TIER levetiracetam CHANGE TIER 04/01/2018 HERCEPTIN trastuzumab 04/01/2018 ALUNBRIG brigatinib 04/01/2018 ALUNBRIG brigatinib ADD UM: QUANTITY 30 / 30 DAYS 04/01/2018 ALUNBRIG brigatinib 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 DAYS 04/01/2018 ELIQUIS apixaban PAGE 10 UPDATED 11/2018
11 04/01/2018 ELIQUIS apixaban ADD UM: QUANTITY 148 / 365 OVER 04/01/2018 CINVANTI aprepitant 04/01/2018 ZENPEP lipase/protease/amylase 04/01/ /01/2018 tenofovir disoproxil fumarate tenofovir disoproxil fumarate 04/01/2018 atazanavir sulfate atazanavir sulfate 04/01/2018 atazanavir sulfate atazanavir sulfate 04/01/2018 atazanavir sulfate atazanavir sulfate 04/01/2018 doripenem doripenem 04/01/2018 carvedilol er carvedilol phosphate 04/01/2018 carvedilol er carvedilol phosphate 04/01/2018 carvedilol er carvedilol phosphate 04/01/2018 NUCALA mepolizumab CHANGE UM: QUANTITY 1 / 28 days 3 / 28 DAYS 04/01/2018 levonorgestreleth 04/01/2018 medroxyprogeste rone acetate 04/01/2018 medroxyprogeste rone acetate levonorgestrel-ethinyl medroxyprogesterone acetate medroxyprogesterone acetate REMOVE UM: QUANTITY CHANGE TIER CHANGE UM: QUANTITY 91 / 91 days 1 / 90 DAYS PAGE 11 UPDATED 11/2018
12 May, /01/2018 naloxone hcl naloxone hcl 05/01/2018 digox digoxin CHANGE TIER 05/01/2018 digox digoxin 05/01/2018 digox digoxin ADD UM: QUANTITY 30 / 30 DAYS 05/01/2018 ZENPEP lipase/protease/amylase 05/01/2018 ZENPEP lipase/protease/amylase 05/01/2018 XTAMPZA ER oxycodone myristate 05/01/2018 XTAMPZA ER oxycodone myristate 05/01/2018 XTAMPZA ER oxycodone myristate 05/01/2018 XTAMPZA ER oxycodone myristate 05/01/2018 XTAMPZA ER oxycodone myristate 05/01/2018 haloperidol lactate haloperidol lactate 05/01/2018 ENDARI glutamine 05/01/2018 QVAR REDIHALER 05/01/2018 QVAR REDIHALER 05/01/2018 QVAR REDIHALER 05/01/2018 QVAR REDIHALER beclomethasone dipropionate beclomethasone dipropionate beclomethasone dipropionate beclomethasone dipropionate ADD UM: QUANTITY ADD UM: QUANTITY 21.2 / 30 DAYS 21.2 / 30 DAYS 05/01/2018 SYMDEKO tezacaftor/ivacaftor 05/01/2018 SYMDEKO tezacaftor/ivacaftor ADD UM: QUANTITY 56 / 28 DAYS PAGE 12 UPDATED 11/2018
13 05/01/2018 ERLEADA apalutamide 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 30 / 30 DAYS 05/01/2018 efavirenz efavirenz 05/01/2018 abacavir abacavir sulfate 05/01/2018 VIDEX EC didanosine 05/01/2018 trientine hcl trientine hcl 05/01/2018 efavirenz efavirenz 05/01/2018 isotretinoin isotretinoin 05/01/2018 levonorg-eth estrad eth estrad 05/01/2018 levonorg-eth estrad eth estrad 05/01/2018 sumatriptan succnaproxen sod 05/01/2018 sumatriptan succnaproxen sod levonorgestrel/ethinyl and ethinyl levonorgestrel/ethinyl and ethinyl sumatriptan succinate/naproxen sodium sumatriptan succinate/naproxen sodium ADD UM: QUANTITY ADD UM: QUANTITY 91 / 91 DAYS 9 / 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 13 UPDATED 11/2018
14 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 isotretinoin isotretinoin 05/01/2018 isotretinoin isotretinoin 05/01/2018 isotretinoin isotretinoin 05/01/2018 nolix flurandrenolide PAGE 14 UPDATED 11/2018
15 June, /01/2018 ABILIFY MAINTENA aripiprazole 06/01/2018 ALIMTA pemetrexed disodium 06/01/2018 DALIRESP roflumilast 06/01/2018 EPIPEN 2-PAK epinephrine 06/01/2018 EPIPEN JR 2- PAK epinephrine 06/01/2018 glatopa glatiramer acetate 06/01/2018 glatopa glatiramer acetate ADD UM: QUANTITY 12 / 28 DAYS 06/01/2018 HAEGARDA c1 esterase inhibitor 06/01/2018 HAEGARDA c1 esterase inhibitor 06/01/2018 hydrocortisonepramoxine hydrocortisone acetate/pramoxine hcl 06/01/2018 ILARIS canakinumab/pf 06/01/2018 ILARIS canakinumab/pf ADD UM: QUANTITY 2 / 28 DAYS 06/01/2018 IMBRUVICA ibrutinib 06/01/2018 IMBRUVICA ibrutinib 06/01/2018 IMBRUVICA ibrutinib 06/01/2018 IMBRUVICA ibrutinib 06/01/2018 IMBRUVICA ibrutinib 06/01/2018 INTRON A interferon alfa-2b,recomb. 06/01/2018 ISENTRESS HD raltegravir potassium 06/01/2018 kelnor 1-50 ethynodiol diacetate-ethinyl PAGE 15 UPDATED 11/2018
16 06/01/2018 lamotrigine,lamot rigine (blue) 06/01/2018 lamotrigine,lamot rigine (green) 06/01/2018 lamotrigine,lamot rigine (orange) lamotrigine lamotrigine lamotrigine 06/01/2018 lansoprazole lansoprazole 06/01/2018 lansoprazole lansoprazole ADD UM: QUANTITY 30 / 30 DAYS 06/01/2018 lansoprazole lansoprazole 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 06/01/2018 mesalamine mesalamine 06/01/2018 ORFADIN nitisinone 06/01/2018 palonosetron hcl palonosetron hcl 06/01/2018 palonosetron hcl palonosetron hcl 06/01/2018 PLEGRIDY peginterferon beta-1a 06/01/2018 PLEGRIDY peginterferon beta-1a ADD UM: QUANTITY 2 / 365 OVER 06/01/2018 ritonavir ritonavir 06/01/2018 RUBRACA rucaparib camsylate 06/01/2018 RUBRACA rucaparib camsylate ADD UM: QUANTITY 120 / 30 DAYS 06/01/2018 SYLVANT siltuximab PAGE 16 UPDATED 11/2018
17 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 30 / 30 DAYS 06/01/2018 SYNAGIS palivizumab 06/01/2018 tiagabine hcl tiagabine hcl 06/01/2018 tiagabine hcl tiagabine hcl 06/01/2018 TRESIBA FLEXTOUCH U /01/2018 TRESIBA FLEXTOUCH U /01/2018 triamcinolone acetonide 06/01/2018 tydemy drospirenone/ethinyl /levomefolate calcium insulin degludec insulin degludec triamcinolone acetonide 06/01/2018 VIRAMUNE nevirapine 06/01/2018 ZYTIGA abiraterone acetate PAGE 17 UPDATED 11/2018
18 July, /01/2018 virtussin ac codeine phosphate/guaifenesin 07/01/2018 HUMIRA adalimumab 07/01/2018 HUMIRA PEDIATRIC CROHN'S adalimumab 07/01/2018 HUMIRA PEN adalimumab 07/01/2018 HUMIRA PEDIATRIC CROHN'S adalimumab 07/01/2018 HUMIRA adalimumab 07/01/2018 ZENPEP lipase/protease/amylase 07/01/2018 BENZNIDAZOLE benznidazole 07/01/2018 BENZNIDAZOLE benznidazole 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 er 07/01/2018 methylphenidate er insulin glargine,human recombinant analog methylphenidate hcl methylphenidate hcl ADD UM: QUANTITY 30 / 30 DAYS 07/01/2018 TASIGNA nilotinib hcl PAGE 18 UPDATED 11/2018
19 07/01/2018 methylphenidate la,methylphenidat e er 07/01/2018 methylphenidate la,methylphenidat e er methylphenidate hcl methylphenidate hcl ADD UM: QUANTITY 180 / 30 DAYS PAGE 19 UPDATED 11/2018
20 August, /01/2018 baclofen baclofen 08/01/2018 baclofen baclofen REMOVE FROM FORMULARY Non-Formulary 08/02/2018 ciprofloxacin hcl ciprofloxacin hcl 08/02/2018 estarylla norgestimate-ethinyl 08/02/2018 mili norgestimate-ethinyl 08/02/2018 tri-mili norgestimate-ethinyl 08/02/2018 baclofen baclofen Non-Formulary 08/02/2018 colesevelam hcl colesevelam hcl 08/02/2018 SYNJARDY XR empagliflozin/metformin hcl 08/02/2018 SYNJARDY XR empagliflozin/metformin hcl ADD UM: QUANTITY 30 / 30 DAYS 08/02/2018 SYNJARDY XR empagliflozin/metformin hcl 08/02/2018 SYNJARDY XR empagliflozin/metformin hcl ADD UM: QUANTITY 60 / 30 DAYS 08/02/2018 SYNJARDY XR empagliflozin/metformin hcl 08/02/2018 SYNJARDY XR empagliflozin/metformin hcl ADD UM: QUANTITY 30 / 30 DAYS 08/02/2018 SYNJARDY XR empagliflozin/metformin hcl 08/02/2018 SYNJARDY XR empagliflozin/metformin hcl ADD UM: QUANTITY 60 / 30 DAYS 08/02/2018 HUMIRA adalimumab 08/02/2018 NORVIR ritonavir 08/02/2018 SYMFI efavirenz/lamivudine/tenofov ir disoproxil fumarate PAGE 20 UPDATED 11/2018
21 08/02/2018 SYMFI efavirenz/lamivudine/tenofov ir disoproxil fumarate ADD UM: QUANTITY 30 / 30 DAYS 08/02/2018 TAVALISSE fostamatinib disodium 08/02/2018 TAVALISSE fostamatinib disodium ADD UM: QUANTITY 60 / 30 DAYS 08/02/2018 TAVALISSE fostamatinib disodium 08/02/2018 TAVALISSE fostamatinib disodium ADD UM: QUANTITY 60 / 30 DAYS 08/02/2018 JYNARQUE tolvaptan 08/02/2018 JYNARQUE tolvaptan ADD UM: QUANTITY 56 / 28 DAYS 08/02/2018 JYNARQUE tolvaptan 08/02/2018 JYNARQUE tolvaptan ADD UM: QUANTITY 56 / 28 DAYS 08/02/2018 JYNARQUE tolvaptan 08/02/2018 JYNARQUE tolvaptan ADD UM: QUANTITY 56 / 28 DAYS 08/21/2018 GLEOSTINE lomustine 08/21/2018 GLEOSTINE lomustine 08/21/2018 GLEOSTINE lomustine PAGE 21 UPDATED 11/2018
22 October, /01/2018 budesonide er budesonide 10/01/2018 BROMSITE bromfenac sodium 10/01/2018 BROMSITE bromfenac sodium ADD UM: QUANTITY 20 / 365 OVER 10/01/2018 TRELEGY ELLIPTA 10/01/2018 TRELEGY ELLIPTA fluticasone furoate/umeclidinium bromide/vilanterol trifenat fluticasone furoate/umeclidinium bromide/vilanterol trifenat 10/01/2018 CIMDUO lamivudine/tenofovir disoproxil fumarate 10/01/2018 CIMDUO lamivudine/tenofovir disoproxil fumarate 10/01/2018 YONSA abiraterone acetate, submicronized ADD UM: QUANTITY ADD UM: QUANTITY 60 / 30 DAYS 30 / 30 DAYS 10/01/2018 LUCEMYRA lofexidine hcl 10/01/2018 LUCEMYRA lofexidine hcl ADD UM: QUANTITY 480 / 30 DAYS 10/01/2018 OLUMIANT baricitinib 10/01/2018 XELJANZ tofacitinib citrate 10/01/2018 miglustat miglustat 10/01/2018 ILEVRO nepafenac CHANGE UM: QUANTITY 6 / 30 days 6 / 30 OVER 10/01/2018 COTELLIC cobimetinib fumarate REMOVE UM: QUANTITY 90 / 30 days 10/02/2018 oseltamivir phosphate oseltamivir phosphate CHANGE UM: QUANTITY 110 / 365 days 110 / 365 OVER PAGE 22 UPDATED 11/2018
23 10/02/2018 ESTRING CHANGE UM: QUANTITY 1 / 90 days 1 / 90 OVER PAGE 23 UPDATED 11/2018
24 November, /01/2018 HUMIRA PEN CROHN-UC-HS STARTER 11/01/2018 HUMIRA PEN PSORIASIS- UVEITIS adalimumab adalimumab 11/01/2018 RHOPRESSA netarsudil mesylate 11/01/2018 RHOPRESSA netarsudil mesylate ADD UM: QUANTITY 2.5 / 25 DAYS 11/01/2018 incassia norethindrone 11/01/2018 ALPHAGAN P brimonidine tartrate 11/01/2018 SPIRIVA RESPIMAT 11/01/2018 STIOLTO RESPIMAT tiotropium bromide CHANGE UM: QUANTITY 4 / 30 days 8 / 28 DAYS tiotropium bromide/olodaterol hcl CHANGE UM: QUANTITY 4 / 30 days 8 / 28 DAYS PAGE 24 UPDATED 11/2018
UPHP Advantage (HMO) (H ) and UPHP Choice (HMO) (H ) Updates
March, 2018 03/01/2018 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
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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
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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
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
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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 Shield 65 Plus Choice Plan (HMO) Blue Shield of California is an independent member of the Blue Shield Association. Formulary Updates:
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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
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Drug Name Description of Change Formulary Coverage Formulary Alternative(s)
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Reason for change. Recently approved. Recently approved. Recently approved. Recently approved. Recently updated. Recently approved.
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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
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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
TennCare Program TN MAC Price Change List As of: 03/30/2017
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JANUVIA 50 MG TABLET BYDUREON 2 MG/0.65 ML JARDIANCE 10 MG TABLET SUBCUTANEOUS PEN INJECTOR JARDIANCE 25 MG TABLET BYDUREON BCISE 2 MG/0.
ANTI DIABETICS BYDUREON 2 MG SUBCUTANEOUS JANUVIA 25 MG TABLET EXTENDED RELEASE SUSPENSION JANUVIA 50 MG TABLET BYDUREON 2 MG/0.65 ML JARDIANCE 10 MG TABLET SUBCUTANEOUS PEN INJECTOR JARDIANCE 25 MG TABLET
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ALBUTEROL - SCORE Ventolin Hfa Trial of ProAir Formulary ID: 18349, Ver.15 Last Updated 10/23/2018 Effective Date: 11/1/2018 1 ANTIDEPRESSANTS - SCORE Aplenzin Desvenlafaxine Er TB24 100MG, 50MG Emsam
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Added, Removed or Changed. Added, Removed or Changed
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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
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Step Therapy Requirements
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MEDICAID QUANTITY LIMIT DRUG LIST PH51-R-02162018 Brand Name Generic Name Dosage Form Tier Quantity Limit Details Cambia Diclofenac Potassium PACK Tier 2 QL: 9 per 30 days Fentanyl (12 Mcg/Hr, 25 Mcg/
THERAPEUTIC AREA NAME STRENGTH DOSAGE FORM
Value Based Tier Drugs are selected for the management of Asthma, Diabetes, Hypertension and Hyperlipidemia. These drugs are covered at no charge or at a reduced cost share. Medications are under continual
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Step Therapy Requirements
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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
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
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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
December 2016 Formulary Updates
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Your prescription benefit updates Formulary Updates - Effective January 1, 2019
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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
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