NOTIFICATION OF FORMULARY CHANGES
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- Tiffany Cameron Dickerson
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1 NOTIFICATION OF CHANGES The following summary describes changes to the 2018 Presbyterian Senior Care (HMO)/(HMO-POS), Presbyterian MediCare PPO and formularies. The formulary may change at any time. You will receive notice when required. For the most recent list of drugs, information on obtaining a coverage determination or exception, or other questions, please contact the Presbyterian Customer Service Center. Presbyterian Senior Care (HMO)/(HMO-POS) and Presbyterian Medicare PPO members may call (0) or (TTY 711). members may call (0) or (TTY 711). October 1 to February 1, we are available from 8 a.m. to 8 p.m. seven days a week. February 1 to September 0, we are available from 8 a.m. to 8 p.m. Monday to Friday. We are closed on holidays. Online: Y00_MPC08171_Accepted_ Last Updated: 0/20/2018 Page 1 of 1
2 0/01/2018 ABACAVIR 20 MG/ML ORAL SOLUTION 0/01/2018 ALOGLIPTIN / METFORMIN 12. MG / 1000 MG, 12.MG / 00MG 0/01/2018 ALOGLIPTIN 12. MG, 2MG, 6.2MG 0/01/2018 ATAZANAVIR 200 MG, 10MG, 00MG CAPSULE 0/01/2018 CASPOFUNGIN 0MG INJECTION 0/01/2018 CASPOFUNGIN 70MG INJECTION 0/01/2018 DACTINOMYCIN 0. MG INTRAVENOUS INJECTION 0/01/2018 EFAVIRENZ 200 MG CAPSULE 0/01/2018 EFAVIRENZ 0 MG ORAL CAPSULE 0/01/2018 ESTRADIOL 0.01 MG VAGINAL 0/01/2018 ESTRADIOL 0.1 MG/ML VAGINAL CREAM ST QL 2 PER DAY ST QL 1 PER DAY Y00_MPC08171_Accepted_ Last Updated: 0/20/2018 Page 2 of 1
3 0/01/2018 ETHINYL ESTRADIOL 0.0 MG / ETHYNODIOL 1 MG / INERT INGREDIENTS 1 MG PACK 0/01/2018 FOSAMPRENAVIR 700 MG 0/01/2018 IMATINIB MESYLATE TAB 100 MG 0/01/2018 IMATINIB MESYLATE TAB 00 MG 0/01/2018 OSELTAMIVIR 6 MG/ML ORAL SUSPENSION 0/01/2018 PRASUGREL 10 MG & MG 0/01/2018 SCOPOLAMINE MG/HR TRANSDERMAL SYSTEM 0/01/2018 SEVELAMER CARBONATE 800 MG 0/01/2018 SODIUM PHENYLBUTYRATE 00 MG 0/01/2018 TENOFOVIR DISOPROXIL FUMARATE 00 MG 0/01/2018 TIMOLOL MG/ML OPHTHALMIC SOLUTION 0/01/2018 TRIKLO 1 GM CAPSULE QL 6 PER DAY QL 2 PER DAY QL 60ML PER 180 DAYS PA QL 1 PER DAY PA QL 10 PER 0 DAYS QL PER DAY Y00_MPC08171_Accepted_ Last Updated: 0/20/2018 Page of 1
4 0/01/2018 VIGABATRIN 0 MG/ML ORAL SOLUTION 0/01/2018 ADACEL VACCINE 0/01/2018 ADCETRIS INTRAVENOUS INFUSION 0/01/2018 ALIQOPA 60MG INJECTION 0/01/2018 ALUNBRIG 90MG & 180MG 0/01/2018 AMPICILLIN 10GM INJECTION 0/01/2018 AMPICILLIN-SULBACTAM SOLUTION (2-1) GM INTRAVENOUS 0/01/2018 ARIPIPRAZOLE 1MG/ML ORAL SOLUTION 0/01/2018 ARISTADA ARIPIPRAZOLE LAUROXIL 276 MG/ML 1.6ML, 276MG/ML 2.ML, 276 MG/ML.2ML PREFILLED SYRINGE 0/01/2018 AZURETTE /0.01 MG 0/01/2018 BENLYSTA 200MG/ML AUTO- INJECTOR QL 1 PER DAY SP QL ML PER 28 DAYS SP Y00_MPC08171_Accepted_ Last Updated: 0/20/2018 Page of 1
5 0/01/2018 BENLYSTA 200MG/ML PREFILLED SYRINGE 0/01/2018 BETAMETHASONE DIPROPIONATE/AUGMENTED GEL 0.0% 0/01/2018 BORTEZOMIB.MG INTRAVENOUS INJECTION 0/01/2018 BOSULIF 00MG 0/01/2018 BYDUREON BCISE 2. MG/ML AUTO-INJECTOR 0/01/2018 CALQUENCE 100MG CAPSULE 0/01/2018 DESOGESTREL 0.1 MG / ETHINYL ESTRADIOL 0.0 MG / INERT INGREDIENTS 1 MG 0/01/2018 DEXAMETHASONE SODIUM PHOSPHATE PF SOLUTION 10 MG/ML INJECTION 0/01/2018 DOXYCYCLINE HYCLATE 100MG INJECTION 0/01/2018 ELIQUIS STARTER PACK QL SYRINGES PER 28 DAYS SP QL1 PER DAY QL.ML PER 28 DAYS QL2 PER DAY PA Y00_MPC08171_Accepted_ Last Updated: 0/20/2018 Page of 1
6 0/01/2018 ERY-TAB DELAYED RELEASE 20 MG, 00 MG 0/01/2018 FIASP 100 UNITS/ML FLEXPEN 0/01/2018 FIASP 100 UNITS/ML VIAL 0/01/2018 GENTAMICIN INJECTION SOLUTION 10 MG/ML 0/01/2018 GLATIRAMER ACETATE 20 MG/ML SUB-Q INJECTION 0/01/2018 GLATIRAMER ACETATE 0 MG/ML SUB-Q INJECTION 0/01/2018 GLUCOSE INTRAVENOUS SOLUTION % 0/01/2018 HALOPERIDOL DECANOATE 100 MG/ML INJECTION 0/01/2018 HAVRIX INJECTION 0/01/2018 HAVRIX PREFILLED SYRINGE 0/01/2018 HEPARIN SODIUM INJECTION UNITS/ML 0/01/2018 HEPARIN SODIUM/NACL INJECTION 2UNIT/ML QL ML PER 0 DAYS QL 0 ML PER 0 DAYS ST QL1 PER DAY ST QL 12 ML PER 28 DAYS Y00_MPC08171_Accepted_ Last Updated: 0/20/2018 Page 6 of 1
7 0/01/2018 HUMALOG INSULIN PEN INJECTOR 0/01/2018 IBU 00MG, 600MG, 800MG 0/01/2018 IDHIFA 0 MG, 100 MG 0/01/2018 ISENTRESS HD 600MG Y00_MPC08171_Accepted_ Last Updated: 0/20/2018 Page 7 of 1 0/01/2018 ISIBLOOM 28 DAY PACK 0/01/2018 JULUCA 0MG/2MG 0/01/2018 KADCYLA 160MG INJECTION 0/01/2018 KLOR-CON 20 MEQ POWDER FOR ORAL SOLUTION 0/01/2018 LARTRUVO 10 MG/ML 19ML VIAL FOR INTRAVENOUS INFUSUIB 0/01/2018 LEUCOVORIN 0MG INJECTION 0/01/2018 LEVO-T 0.02MG, 0.0MG, 0.07MG, 0.088MG, 0.1MG, 0.112MG, 0.12MG, 0.17MG, 0.1MG, 0.17MG, 0.2MG, 0.MG QL ML PER 0 DAYS 1 GC QL1 PER DAY
8 0/01/2018 LEVOTHYROXINE- LIOTHYRONINE 120 MG, 1 MG, 0 MG 0/01/2018 LILLOW 0.1 MG /0 MCG PACK 0/01/2018 LIPODOX 2MG/ML INJECTION 0/01/2018 LOPREEZA MG, 1-0.MG PACK 0/01/2018 LYNPARZA 100 MG, 10MG 0/01/2018 MAVYRET 100 MG/0 MG 0/01/2018 MEROPENEM 1000 MG INTRAVENOUS INJECTION 0/01/2018 METHOTREXATE 2 MG/ML 10ML VIAL FOR INJECTION 0/01/2018 METHYLPHENIDATE EXTENDED RELEASE 27MG, MG 0/01/2018 METHYLPHENIDATE EXTENDED RELEASE 6MG 0/01/2018 MORGIDOX 100MG CAPSULE PA QL PER DAY QL PER DAY QL1 PER DAY QL2 PER DAY Y00_MPC08171_Accepted_ Last Updated: 0/20/2018 Page 8 of 1
9 0/01/2018 MOXIFLOXACIN MG/ML OPHTHALMIC SOLUTION 0/01/2018 MYLOTARG. MG INTRAVENOUS INJECTION 0/01/2018 NERLYNX 0 MG ORAL 0/01/2018 NORETHINDRONE-ETHINYL ESTRADIOL 1-20 MG-MCG Y00_MPC08171_Accepted_ Last Updated: 0/20/2018 Page 9 of 1 0/01/2018 NORLYDA 0.MG 0/01/2018 NP THYROID 120MG 0/01/2018 OCREVUS 00MG/10ML INTRAVENOUS SOLUTION 0/01/2018 OKEBO ORAL CAPSULE 100 MG 0/01/2018 OPDIVO 10 MG/ML INTRAVENOUS INJECTION 0/01/2018 ORENCIA 12MG/ML 0.ML PREFILLED SYRINGE, 0.7ML PREFILLED SYRINGE 0/01/2018 ORFADIN 20 MG CAPSULE 0/01/2018 OXALIPLATIN 100 MG INTRAVENOUS INJECTION QL6 PER DAY SP QL ML PER 28 DAYS
10 0/01/2018 PIPERACILLIN 2000 MG / TAZOBACTAM 20 MG INTRAVENOUS INJECTION 0/01/2018 POLYETHYLENE GLYCOL MG / POTASSIUM CHLORIDE 2980 MG / SODIUM BICARBONATE 6720 MG / SODIUM CHLORIDE 80 MG / SODIUM SULFATE MG POWDER FOR ORAL SOLUTION 0/01/2018 POTASSIUM CHLORIDE EXTENDED RELEASE 10 MEQ 0/01/2018 PREDNISOLONE ORAL SYRUP 1 MG/ML 0/01/2018 PROCTO-MED HC 2.% CREAM 0/01/2018 PROFENO 600MG 0/01/2018 QVAR REDIHALER 0MCG/ACTUATION MDI 0/01/2018 QVAR REDIHALER 80MCG/ACTUATION MDI Y00_MPC08171_Accepted_ Last Updated: 0/20/2018 Page 10 of 1
11 0/01/2018 RESTASIS MULTIDOSE BOTTLE 0.0% 0/01/2018 RITUXAN 10 MG/ML 10ML VIAL FOR INTRAVENOUS INFUSION 0/01/2018 SHINGRIX VARICELLA ZOSTER VIRUS GLYCOPROTEIN E, RECOMBINANT 0.1 MG/ML INJECTION 0/01/2018 TREANDA 2MG INTRAVENOUS SOLUTION 0/01/2018 TRI FEMYNOR 0.18-/0.21- /0.2- MG-MCG PACK 0/01/2018 TRIDERM EXTERNAL CREAM 0.% 0/01/2018 TRISENOX 0/01/2018 TWINRIX VACCINE 0.02 MG/ML PREFILLED SYRINGE 0/01/2018 VAQTA VACCINE 0.ML INJECTION 0/01/2018 VAQTA VACCINE 1ML INJECTION QL 16. ML PER 90 DAYS Y00_MPC08171_Accepted_ Last Updated: 0/20/2018 Page 11 of 1
12 0/01/2018 VARIZIG IMMUNE GLOBULIN 10 UNT/ML INJECTION 0/01/2018 VERZENIO 100MG, 10MG, 200MG & 0MG Y00_MPC08171_Accepted_ Last Updated: 0/20/2018 Page 12 of 1 0/01/2018 VYXEOS INJECTION 0/01/2018 XATMEP 2. MG/ML ORAL SOLUTION 0/01/2018 XERMELO 20 MG 0/01/2018 ZYTIGA 00MG 0/01/ ML SUMATRIPTAN 12 MG/ML PREFILLED SYRINGE 0/01/2018 AMPICILLIN 2 MG/ML ORAL SUSPENSION 0/01/2018 AMPICILLIN 20 MG ORAL CAPSULE 0/01/2018 AMPICILLIN 0 MG/ML ORAL SUSPENSION 0/01/2018 LORTAB 2 MG / MG 0/01/2018 LORTAB 2 MG / 7. MG 0/01/2018 LORTAB 2 MG / 10 MG QL2 PER DAY PA QL PER DAY SP QL 2 PER DAY SP HYDROCODONE/APAP 2MG / MG QL 6 PER DAY HYDROCODONE/APAP 2MG / 7.MG QL 6 PER DAY HYDROCODONE/APAP 2MG / 10MG QL 6 PER DAY
13 0/01/2018 MENOMUNE A/C/Y/W-1 VACCINE 0/01/2018 NECON 1/0 28 DAY PACK 0/01/2018 ARISTADA 27 MG/ML.9 ML PREFILLED SYRINGE 0/01/2018 ROSUVASTATIN 10 MG, 20MG, 0MG, MG REMOVE PA TIER DECREASED Presbyterian MediCare PPO 0/01/2018 TOPOSAR 1GM/0ML INTRAVENOUS TIER DECREASED 0/01/2018 CORMAX TOPICAL SOLUTION 0.0% 0/01/2018 NYATA UNIT/1G POWDER PACK 0/01/2018 TENOFOVIR 00 MG 0/01/2018 HERCEPTIN 10MG INTRAVENOUS RECONSTITUTED SOLUTION 0/01/2018 ALUNBRIG TITRATION PACK 0/01/2018 ELIQUIS 0-DAY STARTER PACK 0/01/2018 ENSKYCE 28 DAY PACK PACKAGE SIZE QL 1 PER DAY SP PA CLOBETASOL EXTERNAL SOLUTION 0.0% TIER NYSTATIN UNITS/1GM POWDER PACK TIER 1 GC Y00_MPC08171_Accepted_ Last Updated: 0/20/2018 Page 1 of 1
14 0/01/2018 HYDROCHLOROTHIAZIDE 12.MG 0/01/2018 LYRICA CR 82.MG, 16MG, 0MG 0/01/2018 MONUROL 000MG POWDER FOR ORAL SOLUTION 0/01/2018 SELZENTRY 20MG/ML ORAL SOLUTION 0/01/2018 SHINGRIX ZOSTER VACCINE INTRAMUSCULAR INJECTION 0/01/201/ XIGDUO 10MG/1000MG, 10MG/00MG, MG/00MG 0/01/2018 XIGDUO 2.MG/1000MG, MG/1000MG 0/01/2018 ALTAVERA 28 DAY PACK 0/01/2018 ALUNBRIG 90MG & 180MG 0/01/2018 ATAZANAVIR 200 MG, 10MG, 00MG CAPSULE 0/01/2018 ESTRADIOL 0.1 MG/ML VAGINAL CREAM ADDTION REC D RXCUI REC D RXCUI REC D RXCUI REC D RXCUI PA QL 1 PER DAY ST QL 1 PER DAY ST QL 2 PER DAY QL 1 PER DAY SP Y00_MPC08171_Accepted_ Last Updated: 0/20/2018 Page 1 of 1
15 0/01/2018 ETHINYL ESTRADIOL 0.0 MG / INERT INGREDIENTS 1 MG / LEVONORGESTREL 0.1 MG 0/01/2018 KURVELO PACK 0/01/2018 MEDROXYPROGESTERONE ACETATE 10 MG/ML PREFILLED SYRINGE REC D RXCUI REC D RXCUI REC D RXCUI Presbyterian MediCare PPO PA = Prior Authorization required, QL = Quantity Limit, SP = Specialty Pharmacy required, ST = Step Therapy, GC = Gap Coverage, B/D = This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1 of each year. Presbyterian Senior Care (HMO)/(HMO-POS) and Presbyterian MediCare PPO are Medicare Advantage plans with Medicare contracts. Enrollment in Presbyterian Senior Care (HMO)/(HMO- POS) and Presbyterian MediCare PPO depends on contract renewal. Presbyterian Dual Plus is an HMO Special Needs Plan (SNP) with a Medicare contract and a contract with the State of New Mexico Human Services Department Medicaid program. Enrollment in depends on contract renewal. Y00_MPC08171_Accepted_ Last Updated: 0/20/2018 Page 1 of 1
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