EFFECTIVE 01/04/2019. pimecrolimus 1 % cream (g) - Added to Tier 1 - ST Added: TOPICAL IMMUNOMODULATORS
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1 EFFECTIVE 01/04/2019 pimecrolimus 1 % cream (g) - ST Added: TOPICAL IMMUNOMODULATORS PAGE 1 LAST UPDATED 02/2019
2 EFFECTIVE 01/05/2019 LORBRENA 100 MG TABLET lorlatinib LORBRENA 25 MG TABLET lorlatinib TALZENNA 0.25 MG CAPSULE talazoparib tosylate TALZENNA 1 MG CAPSULE talazoparib tosylate VIZIMPRO 15 MG TABLET dacomitinib VIZIMPRO 30 MG TABLET dacomitinib VIZIMPRO 45 MG TABLET dacomitinib - PA Added: LORLATINIB - PA Added: LORLATINIB - PA Added: TALAZOPARIB - QL Added: 90 / 30 DAYS - PA Added: TALAZOPARIB - PA Added: DACOMITINIB - PA Added: DACOMITINIB - PA Added: DACOMITINIB PAGE 2 LAST UPDATED 02/2019
3 EFFECTIVE 01/10/2019 ACTEMRA ACTPEN 162 MG/0.9 ML tocilizumab nafcillin in dextrose,iso-osm 2 g/100 ml froz.piggy - PA Added: TOCILIZUMAB - Tier Decreased: Tier 2 to Tier 1 nafcillin sodium 2 g vial port levonorgestrel-ethin estradiol mg tablet PAGE 3 LAST UPDATED 02/2019
4 EFFECTIVE 01/11/2019 cinacalcet hcl 30 mg tablet - PA Added: Part D vs Part B cinacalcet hcl 60 mg tablet - PA Added: Part D vs Part B cinacalcet hcl 90 mg tablet - PA Added: Part D vs Part B vancomycin hcl 1.25 g vial PAGE 4 LAST UPDATED 02/2019
5 EFFECTIVE 01/15/2019 XIFAXAN 200 MG TABLET rifaximin XIFAXAN 550 MG TABLET rifaximin - PA Added: RIFAXIMIN - PA Added: RIFAXIMIN PAGE 5 LAST UPDATED 02/2019
6 EFFECTIVE 01/25/2019 CEROVITE JR TABLET CHEW pediatric multivitamin no.158/ferrous fumarate/phytonadione MICRODOT PEN NEEDLE 31GX6MM pen needle, diabetic MICRODOT PEN NEEDLE 32GX4MM pen needle, diabetic MICRODOT PEN NEEDLE 33GX4MM pen needle, diabetic - Added to Tier 3 polyvinyl alcohol/povidone 2.7%-2% drops - Added to Tier 3 PAGE 6 LAST UPDATED 02/2019
7 EFFECTIVE 02/01/2019 vigabatrin 500 mg tablet - PA Added: VIGABATRIN TABLET PAGE 7 LAST UPDATED 02/2019
8 EFFECTIVE 02/05/2019 DAURISMO 100 MG TABLET glasdegib maleate DAURISMO 25 MG TABLET glasdegib maleate VITRAKVI 100 MG CAPSULE larotrectinib sulfate VITRAKVI 20 MG/ML SOLUTION larotrectinib sulfate VITRAKVI 25 MG CAPSULE larotrectinib sulfate XOSPATA 40 MG TABLET gilteritinib fumarate - PA Added: ANTINEOPLASTIC AGENTS Miscellaneous - PA Added: ANTINEOPLASTIC AGENTS Miscellaneous - QL Added: 60 / 30 DAYS - PA Added: ANTINEOPLASTIC AGENTS Miscellaneous - QL Added: 60 / 30 DAYS - PA Added: ANTINEOPLASTIC AGENTS Miscellaneous - QL Added: 300 / 30 DAYS - QL Added: 180 / 30 DAYS - PA Added: ANTINEOPLASTIC AGENTS Miscellaneous - QL Added: 90 / 30 DAYS PAGE 8 LAST UPDATED 02/2019
9 EFFECTIVE 02/08/2019 QC ANTI-DIARRHEAL 2 MG SOFTGEL loperamide hcl TRUE COMFORT PEN NDL 31GX5MM pen needle, diabetic TRUE COMFORT PEN NDL 31GX6MM pen needle, diabetic TRUE COMFORT PEN NDL 32GX4MM pen needle, diabetic - Added to Tier 3 sirolimus 1 mg/ml solution - PA Added: Part D vs Part B toremifene citrate 60 mg tablet PAGE 9 LAST UPDATED 02/2019
10 EFFECTIVE 02/15/2019 MUCUS-CHEST CONG 200 MG/10 ML guaifenesin - Added to Tier 3 ranitidine hcl 75 mg tablet - Added to Tier 3 tadalafil 20 mg tablet - QL Added: 60 / 30 DAYS - PA Added: TADALAFIL PAGE 10 LAST UPDATED 02/2019
11 EFFECTIVE 02/25/2019 naproxen 375 mg tablet dr - ST Added: INFLAMMATION naproxen 500 mg tablet dr - ST Added: INFLAMMATION PAGE 11 LAST UPDATED 02/2019
12 EFFECTIVE 03/01/2019 ARANESP 150 MCG/0.75 ML VIAL darbepoetin alfa in polysorbate 80 VEXOL 1% EYE DROPS rimexolone - PA Removed: DARBEPOETIN - QL Removed: 10 / 30 OVER TIME - PA Removed: OPHTHALMIC CORTICOSTEROIDS PAGE 12 LAST UPDATED 02/2019
EFFECTIVE 01/04/2019. pimecrolimus 1 % cream (g) - Added to Tier 1 - ST Added: TOPICAL IMMUNOMODULATORS
EFFECTIVE 01/04/2019 pimecrolimus 1 % cream (g) - ST Added: TOPICAL IMMUNOMODULATORS PAGE 1 LAST UPDATED 03/2019 EFFECTIVE 01/05/2019 LORBRENA 100 MG TABLET lorlatinib LORBRENA 25 MG TABLET lorlatinib
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Advance Notification of Amendments to the March 2017 Drug Tariff ADDITIONS Part I - Drugs And Preparations Special Container Drug Qty Price Acetylcysteine 600mg capsules 30 39.95 A Caffeine citrate 50mg/5ml
ACYCLOVIR OINT (CCHP2017)
ACYCLOVIR OINT (CCHP2017) acyclovir 5 % topical ointment Step Therapy requires trial of one (1) of the following: oral generic acyclovir, oral generic famciclovir, oral generic valacyclovir. 1 ALPHAGAN
UWSP Student Health Service Pharmacy Formulary updated: 1/2017
UWSP Student Health Service Pharmacy Formulary updated: 1/2017 Medication Name Strength DosageForm Route Acetaminophen 325 MG Tablet Oral Acetaminophen-Codeine #2 300-15 MG Tablet Oral Acetaminophen-Codeine
Care at the Chemist. Formulary
Care at the Chemist Formulary 1 Acute bacterial conjunctivitis Chloramphenicol 0.5% eye drops (10ml) For ages 2 years and over. Chloramphenicol 1% eye oint. (4g) For ages 2 years and over. Allergy Loratadine