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 03/2019
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 - QL Added: 30 / 30 DAYS - PA Added: LORLATINIB - QL Added: 30 / 30 DAYS - PA Added: LORLATINIB - PA Added: TALAZOPARIB - QL Added: 90 / 30 DAYS - QL Added: 30 / 30 DAYS - PA Added: TALAZOPARIB - QL Added: 30 / 30 DAYS - PA Added: DACOMITINIB - QL Added: 30 / 30 DAYS - PA Added: DACOMITINIB - QL Added: 30 / 30 DAYS - PA Added: DACOMITINIB PAGE 2 LAST UPDATED 03/2019
3 EFFECTIVE 01/10/2019 ACTEMRA ACTPEN 162 MG/0.9 ML tocilizumab levonorgestrel-ethin estradiol mg tablet 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 PAGE 3 LAST UPDATED 03/2019
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 03/2019
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 03/2019
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 03/2019
7 EFFECTIVE 02/01/2019 vigabatrin 500 mg tablet - PA Added: VIGABATRIN TABLET PAGE 7 LAST UPDATED 03/2019
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 - QL Added: 30 / 30 DAYS - 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 03/2019
9 EFFECTIVE 02/08/2019 QC ANTI-DIARRHEAL 2 MG SOFTGEL loperamide hcl - Added to Tier 3 sirolimus 1 mg/ml solution - PA Added: Part D vs Part B toremifene citrate 60 mg tablet TRUE COMFORT PEN NDL 31GX5MM pen needle, diabetic TRUE COMFORT PEN NDL 31GX6MM pen needle, diabetic TRUE COMFORT PEN NDL 32GX4MM pen needle, diabetic PAGE 9 LAST UPDATED 03/2019
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 03/2019
11 EFFECTIVE 02/20/2019 loperamide hcl 2 mg capsule - Added to Tier 3 PAGE 11 LAST UPDATED 03/2019
12 EFFECTIVE 02/22/2019 acetaminophen 325 mg tablet - Added to Tier 3 acyclovir 5 % cream (g) fluticasone propion/salmeterol mcg blst w/dev fluticasone propion/salmeterol mcg blst w/dev fluticasone propion/salmeterol mcg blst w/dev - QL Added: 60 / 30 DAYS - QL Added: 60 / 30 DAYS - QL Added: 60 / 30 DAYS PAGE 12 LAST UPDATED 03/2019
13 EFFECTIVE 02/25/2019 naproxen 375 mg tablet dr - ST Added: INFLAMMATION naproxen 500 mg tablet dr - ST Added: INFLAMMATION PAGE 13 LAST UPDATED 03/2019
14 EFFECTIVE 03/01/2019 ARANESP 150 MCG/0.75 ML VIAL darbepoetin alfa in polysorbate 80 - PA Removed: DARBEPOETIN loperamide hcl 2 mg capsule - Added to Tier 3 QC ANTI-DIARRHEAL 2 MG SOFTGEL loperamide hcl SM ANTI-DIARRHEAL 2 MG SOFTGEL loperamide hcl VEXOL 1% EYE DROPS rimexolone - Added to Tier 3 - Added to Tier 3 - QL Removed: 10 / 30 OVER TIME - PA Removed: OPHTHALMIC CORTICOSTEROIDS PAGE 14 LAST UPDATED 03/2019
15 EFFECTIVE 03/05/2019 SYMPAZAN 10 MG FILM clobazam SYMPAZAN 20 MG FILM clobazam SYMPAZAN 5 MG FILM clobazam PAGE 15 LAST UPDATED 03/2019
16 EFFECTIVE 03/08/2019 MAXICOMFORT PEN NDL 29G X 5MM pen needle, diabetic, safety MAXICOMFORT PEN NDL 29G X 8MM pen needle, diabetic, safety PRO COMFORT PEN NDL 4MM 32G pen needle, diabetic ranolazine 1000 mg tab er 12h ranolazine 500 mg tab er 12h SAFETY PEN NEEDLE 5MM X 31G pen needle, diabetic, safety ULTICARE PEN NEEDLES 6MM 32G pen needle, diabetic PAGE 16 LAST UPDATED 03/2019
17 EFFECTIVE 03/11/2019 chlordiazepoxide hcl 10 mg capsule - QL Added: 4 / DAY chlordiazepoxide hcl 25 mg capsule - QL Added: 4 / DAY chlordiazepoxide hcl 5 mg capsule - QL Added: 4 / DAY PAGE 17 LAST UPDATED 03/2019
18 EFFECTIVE 03/15/2019 aliskiren hemifumarate 150 mg tablet - PA Added: ALISKIREN aliskiren hemifumarate 300 mg tablet - PA Added: ALISKIREN CHLD ALLEGRA ALLERGY 30 MG ODT fexofenadine hcl ethinyl estradiol/drospirenone (24) tablet PERSERIS ER 120 MG SYRINGE KIT risperidone PERSERIS ER 90 MG SYRINGE KIT risperidone TREMFYA 100 MG/ML INJECTOR guselkumab - Added to Tier 98 - ST Added: Loratadine - QL Added: 1 / 30 DAYS - PA Added: PERSERIS - QL Added: 1 / 30 DAYS - PA Added: PERSERIS - PA Added: Interleukin 23 Receptor Antagonists PAGE 18 LAST UPDATED 03/2019
19 EFFECTIVE 03/20/2019 clotrimazole 2 % cream/appl - Added to Tier 3 loperamide hcl 2 mg capsule - Added to Tier 3 nicotine 7mg/24hr patch td24 - Added to Tier 3 - QL Added: 28 / 28 DAYS PAGE 19 LAST UPDATED 03/2019
20 EFFECTIVE 03/22/2019 ferrous sulfate 140(45)mg tablet er - Added to Tier 3 polyvinyl alcohol/povidone 0.5%-0.6% drops - Added to Tier 3 pyridostigmine bromide 60 mg/5 ml syrup PAGE 20 LAST UPDATED 03/2019
21 EFFECTIVE 04/01/2019 AIMOVIG 140 MG DOSE-2 AUTOINJ erenumab-aooe AIMOVIG 70 MG/ML AUTOINJECTOR erenumab-aooe amlodipine bes/olmesartan med 10 mg- 20mg tablet amlodipine bes/olmesartan med 10 mg- 40mg tablet amlodipine bes/olmesartan med 5 mg-20 mg tablet amlodipine bes/olmesartan med 5 mg-40 mg tablet amlodipine besylate/valsartan 10mg- 160mg tablet amlodipine besylate/valsartan 10mg- 320mg tablet amlodipine besylate/valsartan 5 mg- 160mg tablet amlodipine besylate/valsartan 5 mg- 320mg tablet - QL Added: 2 ML / 30 DAYS - PA Added: AIMOVIG - QL Added: 2 ML / 30 DAYS - PA Added: AIMOVIG armodafinil 150 mg tablet - QL Added: 30 / 30 DAYS - PA Added: ARMODAFINIL armodafinil 200 mg tablet - QL Added: 30 / 30 DAYS - PA Added: ARMODAFINIL armodafinil 250 mg tablet - QL Added: 30 / 30 DAYS - PA Added: ARMODAFINIL armodafinil 50 mg tablet - QL Added: 30 / 30 DAYS - PA Added: ARMODAFINIL PAGE 21 LAST UPDATED 03/2019
22 EFFECTIVE 04/01/2019 AZOPT 1% EYE DROPS brinzolamide bimatoprost 0.03 % drops citric acid/sodium citrate mg solution DIFFERIN 0.1% GEL adapalene - QL Added: 15 ML / 28 DAYS - ST Added: SIMBRINZA - Added to Tier 3 - Added to Tier 3 - QL Added: 45 / 30 OVER TIME - PA Added: TRETINOIN, TOPICAL fluocinolone acetonide oil 0.01 % drops - QL Added: 20 ML / 30 OVER TIME latanoprost % drops LIBTAYO 350 MG/7 ML VIAL cemiplimab-rwlc - ST Added: SIMBRINZA - PA Added: ONCOLOGY GENERAL lidocaine 4 % cream (g) - Added to Tier 3 LUMIGAN 0.01% EYE DROPS bimatoprost LUMOXITI 1 MG VIAL moxetumomab pasudotox-tdfk NIVESTYM 300 MCG/ML VIAL filgrastim-aafi NIVESTYM 480 MCG/1.6 ML VIAL filgrastim-aafi PIN-X 250 MG (BASE) TAB CHEW pyrantel pamoate RHOPRESSA 0.02% OPHTH SOLUTION netarsudil mesylate - ST Added: SIMBRINZA - PA Added: ONCOLOGY GENERAL - PA Added: FILGRASTIM-AAFI - PA Added: FILGRASTIM-AAFI - Added to Tier 3 - ST Added: RHOPRESSA - QL Added: 5 ML / 30 DAYS PAGE 22 LAST UPDATED 03/2019
23 EFFECTIVE 04/01/2019 SIMBRINZA 1%-0.2% EYE DROPS brinzolamide/brimonidine tartrate SYLVANT 400 MG VIAL siltuximab TRAVATAN Z 0.004% EYE DROP travoprost UDENYCA 6 MG/0.6 ML SYRINGE pegfilgrastim-cbqv VYZULTA 0.024% OPHTH SOLUTION latanoprostene bunod ZIOPTAN % EYE DROPS tafluprost/pf - QL Added: 8 ML / 28 DAYS - ST Added: SIMBRINZA - Removed From Coverage - ST Added: SIMBRINZA - QL Added: 5 ML / 28 DAYS - PA Added: PEGFILGRASTIM - ST Added: SIMBRINZA - QL Added: 5 ML / 28 DAYS - QL Removed: 5 ML / 28 DAYS - ST Added: SIMBRINZA PAGE 23 LAST UPDATED 03/2019
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 02/2019 EFFECTIVE 01/05/2019 LORBRENA 100 MG TABLET lorlatinib LORBRENA 25 MG TABLET lorlatinib
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2018 Formulary Update
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Kansas Health Advantage (HMO SNP) 2018 Formulary Quantity Limit Criteria
APREPITANT Kansas Health Advantage (HMO SNP) 2018 Formulary Aprepitant Oral Capsule 125, 40, 80 Aprepitant Oral Capsule 80 & 125 Quantity Limit: 8 EA Per 30 Days Quantity Limit: 12 EA Per 30 Days ARMODAFINIL
Fruth Pharmacy Prescription Savings Club Prescription Club October 2010 Generics item list 30 Day Qty
Fruth Pharmacy Prescription Savings Club Prescription Club October 2010 Generics item list Antihistamine Drugs Cyproheptadine HCl Tab 4 mg Anti-Infective Agents Diphenhydramine HCl Cap mg Promethazine
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
Y0133_StepTherapyCriteria _C 10/18/18 Y0133_StepTherapyCriteria _C es 10/18/18
Step Therapy Grid Certain cost-effective drugs must be used before other more expensive drugs are covered. For example, certain brand-name medications will only be covered if a generic alternative has
June 2018 Pharmacy & Therapeutics Committee Decisions
UCare s Pharmacy and Therapeutics Committee (P&T) is a group of physicians and pharmacists that meet throughout the year to make changes to the UCare formulary (approved drug list). These changes are reviewed
Drug Schedule For RC 143(A)
DRUGS FOR RESPIRATORY SALBUTAMOL TAB - Each Tab to SYSTEM 1 30a contain:salbutamol 2mg. 1 tab 9600000 100000 200000 SALBUTAMOL TAB - Each Tab to 2 30b contain:salbutamol 4 mg. 1 tab 8000000 80000 160000
Pharmacy Program Updates: Quarterly Pharmacy Changes Effective July 1, 2017
Pharmacy Program Updates: Quarterly Pharmacy Changes Effective July 1, 2017 DRUG LIST CHANGES Based on the availability of new prescription medications and Prime s National Pharmacy and Therapeutics Committee
All Pharmacy Providers and Prescribing Practitioners. Subject: Updated and Revised Over-the-Counter Drug Formulary
Indiana Health Coverage Pros P R O V I D E R B U L L E T I N B T 2 0 0 3 5 8 A U G U S T 2 8, 2 0 0 3 To: All Pharmacy Providers and Prescribing Practitioners Subject: Overview Note: The information referenced
Step Therapy Requirements
An Independent Licensee of the Blue Cross and Blue Shield Association Step Therapy Requirements Effective: 05/01/2018 Updated 4/2018 H0302_2_2014 CMS Accepted 05/05/2014 1 BETA-BLOCKERS BYSTOLIC 10 MG
Riesbeck's Pharmacy Reward Club Generic Medication List October 2017
Allergy, Cold & Flu Antibiotic Treatments Arthritis & Pain Benzonatate 100mg cap 14 42 Diphenhydramine HCl Cap 50 MG 30 90 Diphenhydramine HCl Inj 50MG/ML 1 3 Diphenhydramine HCl Liquid 12.5 MG/5ML 720ml
Aspirin. Iron Supplements
Interim Final Rules for Non-Grandfathered Group Health Plans and Health Insurance Issuers Coverage of Preventive Services Under the Patient Protection and Affordable Care Act Aspirin Aspirin to Prevent
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
2017 Formulary Changes Year to Date
2017 Formulary Changes Year to Date Health Choice Arizona may add or remove drugs from our formulary during the year. If we remove drugs from our formulary, add prior authorization, quantity limits and/or
HEALTH SHARE/PROVIDENCE (OHP)
HEALTH SHARE/PROVIDENCE (OHP) STEP THERAPY This is a complete list of drugs that have written coverage determination policies. Drugs on this list do not indicate that this particular drug will be covered
STEP THERAPY CRITERIA
STEP THERAPY This is a complete list of drugs that have written coverage determination policies. Drugs on this list do not indicate that this particular drug will be covered under your medical or prescription
Superior Select Health Plans: Tribute-1 Tier May 2018 Formulary Addendum
Superior Select Health Plans: Tribute-1 Tier May 2018 Formulary Addendum Below is a list formulary changes for the benefit year 2018. This is not a complete list of drugs covered by the Part D plan. The
2017 Formulary Addendum Notice of Change (Medicare Advantage Plans)
207 Formulary Addendum Notice of Change (Medicare Advantage Plans) Easy Choice Health Plan Easy Choice Plus Plan (HMO) H5087-002, H5087-07 This is a listing of the changes that have occurred in our formulary.
5-ASA. Products Affected DIPENTUM 250 MG CAPSULE LIALDA 1.2 GRAM TABLET,DELAYED RELEASE. Details
5-ASA DIPENTUM 250 MG CAPSULE LIALDA 1.2 GRAM TABLET,DELAYED You are required to have previous therapy with balsalazide, Delzicol, Apriso, or Asacol HD before we will cover Lialda or Dipentum. 1 ANTIEMETICS
FORMULARY Revised January 2018 NOTES ABOUT FORMULARY AND PHARMACY
FORMULARY Revised NOTES ABOUT FORMULARY AND PHARMACY 1. Purposes: Assist team leaders in preparing for trips Limit the number of interchangeable drugs Limit pharmacy errors Improve efficiency and organization
Aetna Better Health of Illinois Medicaid Formulary Updates
October 2017 o DOXYLAMINE SUCCINATE 25mg-QL o DULOXETINE CAP 40MG DR-QL o GUANFACIN ER TABS (all strengths)-ql o TOBRAMYCIN NEBU SOLUTION- PA August 2017 Aetna Better Health of Illinois Medicaid 2017 Formulary
5-ASA. Products Affected. Details. Dipentum 250 mg capsule. Lialda 1.2 gram tablet,delayed release
Updated 11/1/17 5-ASA Dipentum 250 mg capsule Lialda 1.2 gram tablet,delayed release You are required to have previous therapy with balsalazide, Delzicol, Apriso, or Asacol HD before we will cover Lialda
2017 Formulary Addendum Notice of Change (Medicare Advantage Plans)
2017 Formulary Addendum Notice of Change (Medicare Advantage Plans) Easy Choice Health Plan Easy Choice Best Plan (HMO) H5087-005 This is a listing of the changes that have occurred in our formulary. Please
BYSTOLIC. Products Affected Step 2: BYSTOLIC 10 MG TABLET BYSTOLIC 2.5 MG TABLET. Details BYSTOLIC 20 MG TABLET BYSTOLIC 5 MG TABLET
BYSTOLIC BYSTOLIC 10 MG TABLET BYSTOLIC 2.5 MG TABLET BYSTOLIC 20 MG TABLET BYSTOLIC 5 MG TABLET authorization for a Step 2 drug may be given. Step 1 Drug(s): generic beta-blockers and/or combinations,
Quarterly pharmacy formulary change notice
Provider update Quarterly pharmacy formulary change notice Summary: The formulary changes listed in the table below were reviewed and approved at our first-quarter 2018, Pharmacy and Therapeutics Committee
These programs and quantity limitations may not apply. Check your certificate or other plan information for benefit details.
FlexRx Standard Utilization Management (PA, QL,) Updates January 1, 2018 How to use this drug list This drug list includes updates to Utilization Management (UM) programs. UM may include a prior authorization
TEST ANTICONVULSANT THERAPY. Products Affected. Step 2: Network Health Insurance Corporation NetworkCares Step Therapy Criteria Last Updated 11/2018
TEST Network Health Insurance Corporation NetworkCares Step Therapy Last Updated 11/2018 ANTICONVULSANT THERAPY Aptiom Banzel Briviact Celontin Dilantin 30 Mg Capsule Equetro Fycompa 0.5 Mg/ml Oral Susp
WellCare Signature (PDP) and WellCare Classic (PDP) Formulary Addendum
WellCare Signature (PDP) and WellCare Classic (PDP) Formulary Addendum This is a listing of the changes that have occurred in our formulary. Please carefully review these changes and call WellCare if you
Quarterly pharmacy formulary change
Medi-Cal Managed Care L. A. Care Major Risk Medical Insurance Program Provider Bulletin The formulary changes listed in the table below were reviewed and approved at our first-quarter 2018 Pharmacy and
STEP THERAPY CRITERIA
STEP THERAPY This is a complete list of drugs that have written coverage determination policies. Drugs on this list do not indicate that this particular drug will be covered under your medical or prescription
Pharmacy Providers and Prescribing Physicians. Updated Over-the-Counter Drug Formulary
P R O V I D E R B U L L E T I N BT200150 DECEMBER 12, 2001 To: Subject: Pharmacy Providers and Prescribing Physicians Note: The information in this bulletin is not directed to those providers rendering