3 Tier Formulary Additions
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- Joleen McKinney
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1 3 Tier Formulary Additions Drug Name Tier Category Management ACCU-CHECK GUIDE ME GLUCOSE METER 3 Diabetic Supplies Step Therapy applies pyridostigmine bromide 60mg/5ml syrup 1 Antimyasthenic Agents New Generic: Tier 1 QMIIZ ODT 15MG TAB 3 Analgesics DICLOFENAC EPOLAMINE 1.3% PATCH 3 Analgesics CABLIVI 11MG KIT 3 Blood Products/Modifiers/Volume Expanders aliskiren 1 Cardiovascular Agents BENZHYDROCODONE/ACETAMINOPHEN TAB 3 Analgesics New Brand: Tier 3 cyclobenzaprine hcl er cap 1 Skeletal Muscle Relaxants New Generic: Tier 1, Prior
2 EASY STEP CONTROL SOLUTION 3 Diabetic Supplies New Brand: Tier 3 LOTEMAX SM 0.38% DROPS 2 Ophthalmic Agents New Brand: Tier 2 ranolazine er tab 1 Cardiovascular Agents TUXARIN ER TAB 3 Respiratory Tract/Pulmonary Agents New Brand: Tier 3 APADAZ TAB 3 Analgesics New Brand: Tier 3 BIJUVA CAPSULE 3 Stimulant/Replacement/Modifying New Brand: Tier 3 INBRIJA INHALATION CAPSULE 3 Antiparkison and Related Therapy Agents fluticasone-salmeterol inh 1 Respiratory Tract/Pulmonary Agents wixela inhub inh 1 Respiratory Tract/Pulmonary Agents acyclovir 5% cream 1 Antivirals
3 ganirelix acetate syringe 250 MCG/0.5 ML 1 Suppressant New Generic: Tier 1, Prior buprenorphine-naloxone film 1 Anti-Addiction/Substance Abuse Treatment Agents New Generic: Tier 1 MOTEGRITY 3 Antiemetics sevelamer hcl 1 Electrolytes/Minerals/Metals/Vitamins New Generic: Tier 1 toremifene citrate 1 Antineoplastics New Generic: Tier 1 sirolimus 1 Immunological Agents New Generic: Tier 1 LEVORPHANOL TARTRATE 3MG TAB 3 Analgesics Authorization applies SYMJEPI 0.3MG SYR 3 Respiratory Tract/Pulmonary Agents ALBUTEROL SULFATE HFA 2 Respiratory Tract/Pulmonary Agents New Brand: Tier 2, Quantity D-PENAMINE 2 Genitourinary Agents New Brand: Tier 3
4 FIRDAPSE 3 Central Nervous System Agents HALOBETASOL PROPIONATE 0.05% FOAM 3 Stimulant/Replacement/Modifying KRINTAFEL 2 Antiparasitics New Brand: Tier 2 CAPSFENAC PAK 3 Dermatological Agents cinacalcet hcl 1 Metabolic Bone Disease Agents New Generic: Tier 1 tri-vylibra 1 Stimulant/Replacement/Modifying New Generic: Tier 1 pimecrolimus 1% cream 1 Dermatological Agents SEYSARA TAB 3 Antibacterials AEMCOLO 3 Antibacterials New Brand: Tier 3 mesalamine suppositories 1000mg 1 Inflammatory Bowel Disease Agents New Generic: Tier 1
5 aminocaproic acid 500mg tab 1 Blood Products/Modifiers/Volume Expanders New Generic: Tier 1 CEQUA 3 Ophthalmic Agents Quantity NUZYRA 3 Antibacterials New Brand: Tier 3 TOLSURA 3 Antifungals DAURISOMO 3 Antineoplastics UDENYCA SYR 3 Blood Products/Modifiers/Volume Expanders VITRAKVI 3 Antineoplastics XOSPATA 3 Antineoplastics abiraterone acetate 1 Antineoplastics LEDIPASVIR-SOFOSBUVIR 3 Antivirals New Generic: Tier 1, Prior
6 OXERVATE 0.002% DROP 3 Ophthalmic Agents silodosin 1 Genitourinary Agents XYOSTED 3 Stimulant/Replacement/Modifying XELPROS 3 Ophthalmic Agents Quantity testosterone 10mg gel pump 1 Stimulant/Replacement/Modifying New Generic: Tier 1 SYMPAZAN 3 Anticonvulsants LORBRENA 3 Antineoplastics Quantity BRYHALI 3 Stimulant/Replacement/Modifying azelaic acid gel 1 Dermatological Agents New Generic: Tier 1 ABILIFY MYCITE 3 Antipsychotics Quantity
7 YUPELRI 3 Respiratory Tract/Pulmonary Agents INVELTYS 3 Ophthalmic Agents New Brand: Tier 3 GLUCOCARD SHINE EXPRESS METER 3 Diabetic Supplies Step Therapy applies GLUCOCARD SHINE CONNEX METER 3 Diabetic Supplies Step Therapy applies FENOFIBRATE 3 Cardiovascular Agents Quantity ARAKODA 3 Antiparasitics New Brand: Tier 3 LEXETTE 0.05% FOAM 3 Stimulant/Replacement/Modifying MICONAZOLE-ZINC OXIDE-PETROLTM 3 Antifungals New Brand: Tier 3 MINOCYCLINE HCL ER 55MG TAB 3 Antibacterials vardenafil hcl 1 Genitourinary Agents
8 EMBRACE TALK CONTROL SOLUTION 3 Diabetic Supplies New Brand: Tier 3 EMBRACE TALK METER 3 Diabetic Supplies EMBRACE TALK TEST STRIPS 3 Blood Glucose Regulators Step Therapy and Quantity limit applies Step Therapy and Quantity limit applies vitamins A,C,D & fluoride 0.5mg/ml drop 1 Electrolytes/Minerals/Metals/Vitamins New Generic: Tier 1 3/22/2019
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