Medicare Part D 2017 Formulary Changes Service To Senior
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- Dorothy Little
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1 Medicare Part D 2017 Formulary Changes Service To Senior Inter Valley Health Plan may add or remove drugs from our formulary during the year. If we remove a drug from our formulary, add prior authorization, quantity limits and/or step therapy restrictions or move a drug to a higher cost-sharing tier, we will notify you of the change at least 60 days before the date that the change becomes effective. However, if the U.S. Food and Drug Administration (FDA) determines a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary. The table below outlines changes made to our formulary throughout VERSION: FORMULARY ADDITIONS UPDATE AS OF NOVEMBER 1, 2017: FORMULARY ID: Formulary additions, reductions in preferred or tiered cost-sharing status, or removal of Utilization Management to an existing formulary drug Covered Drug Name Alternate Drug Name Description of Change Effective Date of Change Tier Utilization Management Notes ISENTRESS HD TAB 600MG RALTEGRAVIR ADDITION 5 QL (60/30) ZYTIGA TAB 500MG ABIRATERONE ADDITION 5 QL (120/30) NERLYNX TAB 40MG NERATINIB ADDITION 5 IDHIFA TAB 50MG ENASIDENIB ADDITION 5 PA IDHIFA TAB 100MG ENASIDENIB ADDITION 5 PA LYNPARZA TAB 100MG OLAPARIB ADDITION 4 QL (240 PER 30 DAYS), PA LYNPARZA TAB 150MG OLAPARIB ADDITION 4 QL (180 PER 30 DAYS), PA VYXEOS INJ MG DAUNORUBICIN AND CYTARABINE ADDITION 5 PA TYMLOS INJ ABALOPARATIDE ADDITION 4 PA VIGABATRIN PAK 500MG VIGABATRIN ADDITION 5 QL (180/30) PRASUGREL TAB 5MG EFFIENT ADDITION 2 QL (30/30) PRASUGREL TAB 10MG EFFIENT ADDITION 2 QL (30/30) MOXIFLOXACIN SOL 0.5% VIGAMOX ADDITION 1 QL = Quanity Limit, 1
2 Covered Drug Name Alternate Drug Name Description of Change Effective Date of Change Tier Utilization Management Notes NECON TAB 10/11-28 ACETASOL HC SOL OTIC ETHINYL ESTRADIOL AND NORETHINDRONE DELETION 1 ACETIC ACID,PROPYLENE GLYCOL AND HYDROCORTISONE DELETION 2 ATOMOXETINE CAP 10MG STRATTERA ADDITION 10/1/ QL (60 PER 30 DAYS) ATOMOXETINE CAP 18MG STRATTERA ADDITION 10/1/ QL (60 PER 30 DAYS) ATOMOXETINE CAP 25MG STRATTERA ADDITION 10/1/ QL (60 PER 30 DAYS) ATOMOXETINE CAP 40MG STRATTERA ADDITION 10/1/ QL (60 PER 30 DAYS) ATOMOXETINE CAP 60MG STRATTERA ADDITION 10/1/ QL (60 PER 30 DAYS) ATOMOXETINE CAP 80MG STRATTERA ADDITION 10/1/ QL (60 PER 30 DAYS) ATOMOXETINE CAP 100MG STRATTERA ADDITION 10/1/ QL (60 PER 30 DAYS) XATMEP SOL 2.5MG/ML METHOTREXATE ADDITION 10/1/ AMPICILLIN SUS 125/5ML AMPICILLIN DELETION 10/1/ PA AMPICILLIN SUS 250/5ML AMPICILLIN DELETION 10/1/ MENHIBRIX INJ MENINGOCOCCAL POLY AND HAEMOPHILUS B CONJ DELETION 10/1/ ARISTADA INJ 1064MG ARIPIPRAZOLE ADDITION 9/1/ BASAGLAR INJ 100UNIT INSULIN GLARGINE ADDITION 9/1/ GLYCOPYRROLATE AND BEVESPI AER 9-4.8MCG FORMOTEROL ADDITION 9/1/ ENTRESTO TAB 24-26MG SACUBITRIL AND VALSARTAN ADDITION 9/1/ ENTRESTO TAB 49-51MG SACUBITRIL AND VALSARTAN ADDITION 9/1/ PA, (90) PA, (90) ENTRESTO TAB MG SACUBITRIL AND VALSARTAN ADDITION 9/1/ PA, (90) GARDASIL INJ PAPILLOMAVIRUS VACCINE DELETION 9/1/ PA QL = Quanity Limit, 2
3 Covered Drug Name Alternate Drug Name Description of Change Effective Date of Change Tier Utilization Management Notes LOKARA LOT 0.05% DESONIDE DELETION 9/1/ MOLINDONE TAB HCL 10MG MOBAN DELETION 9/1/ MOLINDONE TAB HCL 25MG MOBAN DELETION 9/1/ MOLINDONE TAB HCL 5MG MOBAN DELETION 9/1/ POTIGA TAB 200MG EZOGABINE DELETION 9/1/ QL (180/30) POTIGA TAB 300MG EZOGABINE DELETION 9/1/ QL (120/30) POTIGA TAB 400MG EZOGABINE DELETION 9/1/ QL (90/30) POTIGA TAB 50MG EZOGABINE DELETION 9/1/ QL (720/30) XATMEP SOL 2.5MG/ML METHOTREXATE DELETION 9/1/ PA ALUNBRIG TAB 30MG BRIGATINIB ADDITION 8/1/ PA CLOFARABINE INJ 20/20ML CLOLAR ADDITION 8/1/ PA EZETIM/SIMVA TAB 10-10MG VYTORIN ADDITION 8/1/ QL (30 PER 30 DAYS), (90) EZETIM/SIMVA TAB 10-20MG VYTORIN ADDITION 8/1/ QL (30 PER 30 DAYS), (90) EZETIM/SIMVA TAB 10-80MG VYTORIN ADDITION 8/1/ QL (30 PER 30 DAYS), (90) IMFINZI INJ 120/2.4 DURVALUMAB ADDITION 8/1/ PA IMFINZI INJ 500/10 DURVALUMAB ADDITION 8/1/ PA KISQALI 200 PAK FEMARA RIBOCICLIB AND LETROZOLE ADDITION 8/1/ PA KISQALI 400 PAK FEMARA RIBOCICLIB AND LETROZOLE ADDITION 8/1/ PA KISQALI 600 PAK FEMARA RIBOCICLIB AND LETROZOLE ADDITION 8/1/ PA RYDAPT CAP 25MG MIDOSTAURIN ADDITION 8/1/ PA XATMEP SOL 2.5MG/ML METHOTREXATE ADDITION 8/1/ PA ZEJULA CAP 100MG NIRAPARIB ADDITION 8/1/ PA GARDASIL INJ PAPILLOMAVIRUS VACCINE DELETION 8/1/ PA PEG-INTRON KIT 150 RP PEGINTERFERON ALFA-2b DELETION 8/1/ QL (4 PER 28 DAYS), PA PEG-INTRON KIT 50MCG RP PEGINTERFERON ALFA-2b DELETION 8/1/ QL (4 PER 28 DAYS), PA PEG-INTRON KIT 80MCG RP PEGINTERFERON ALFA-2b DELETION 8/1/ QL (4 PER 28 DAYS), PA BAVENCIO INJ 20MG/ML AVELUMAB ADDITION 7/1/ PA DESVENLAFAX TAB 100MG ER PRISTIQ ADDITION 7/1/ QL (30 PER 30 DAYS) DESVENLAFAX TAB 25MG ER PRISTIQ ADDITION 7/1/ QL (240 PER 30 DAYS) QL = Quanity Limit, 3
4 Covered Drug Name Alternate Drug Name Description of Change Effective Date of Change Tier Utilization Management Notes DESVENLAFAX TAB 50MG ER PRISTIQ ADDITION 7/1/ QL (240 PER 30 DAYS) ESBRIET TAB 267MG PIRFENIDONE ADDITION 7/1/ QL (270 PER 30 DAYS), PA ESBRIET TAB 801MG PIRFENIDONE ADDITION 7/1/ QL (90 PER 30 DAYS), PA LEVOLEUCOVOR INJ 50MG FUSILEV ADDITION 7/1/ PA NITROGLYCERN SUB 0.3MG NITROSTAT ADDITION 7/1/ OSELTAMIVIR CAP 30MG TAMIFLU ADDITION 7/1/ QL (84 PER 180 DAYS) OSELTAMIVIR CAP 45MG TAMIFLU ADDITION 7/1/ QL (42 PER 180 DAYS) OSELTAMIVIR CAP 75MG TAMIFLU ADDITION 7/1/ QL (42 PER 180 DAYS) VIRAZOLE INH 6GM RIBAVIRIN DELETION 7/1/ PA BUTRANS DIS 10MCG/HR BUPRENORPHINE ADDITION 6/1/ QL (4 PER 28 DAYS) BUTRANS DIS 15MCG/HR BUPRENORPHINE ADDITION 6/1/ QL (4 PER 28 DAYS) BUTRANS DIS 20MCG/HR BUPRENORPHINE ADDITION 6/1/ QL (4 PER 28 DAYS) BUTRANS DIS 5MCG/HR BUPRENORPHINE ADDITION 6/1/ QL (4 PER 28 DAYS) BUTRANS DIS 7.5/HR BUPRENORPHINE ADDITION 6/1/ QL (4 PER 28 DAYS) BYDUREON INJ EXENATIDE EXTENDED TIER RELEASE REDUCTION 6/1/ QL (4 PER 28 DAYS) BYDUREON INJ EXENATIDE EXTENDED TIER RELEASE REDUCTION 6/1/ QL (4 PER 28 DAYS) FARXIGA TAB 10MG DAPAGLIFLOZIN ADDITION 6/1/ FARXIGA TAB 5MG DAPAGLIFLOZIN ADDITION 6/1/ FLECTOR DIS 1.3% DICLOFENAC ADDITION 6/1/ HYSINGLA ER TAB 100 MG HYDROCODONE EXTENDED- RELEASE ADDITION 6/1/ QL (60 PER 30 DAYS) HYSINGLA ER TAB 120 MG HYDROCODONE EXTENDED- RELEASE ADDITION 6/1/ QL (60 PER 30 DAYS) HYSINGLA ER TAB 20 MG HYDROCODONE EXTENDED- RELEASE ADDITION 6/1/ QL (60 PER 30 DAYS) HYSINGLA ER TAB 30 MG HYDROCODONE EXTENDED- RELEASE ADDITION 6/1/ QL (60 PER 30 DAYS) QL = Quanity Limit, 4
5 Covered Drug Name Alternate Drug Name Description of Change Effective Date of Change Tier Utilization Management Notes HYSINGLA ER TAB 40 MG HYDROCODONE EXTENDED- RELEASE ADDITION 6/1/ QL (60 PER 30 DAYS) HYSINGLA ER TAB 60 MG HYDROCODONE EXTENDED- RELEASE ADDITION 6/1/ QL (60 PER 30 DAYS) HYSINGLA ER TAB 80 MG HYDROCODONE EXTENDED- RELEASE ADDITION 6/1/ QL (60 PER 30 DAYS) KISQALI TAB 200DOSE RIBOCICLIB ADDITION 6/1/ PA KISQALI TAB 400DOSE RIBOCICLIB ADDITION 6/1/ PA KISQALI TAB 600DOSE RIBOCICLIB ADDITION 6/1/ PA OXYCONTIN TAB 10MG CR OXYCODONE TIER 6/1/ QL (90 PER 30 DAYS) OXYCONTIN TAB 15MG CR OXYCODONE TIER 6/1/ QL (90 PER 30 DAYS) OXYCONTIN TAB 20MG CR OXYCODONE TIER 6/1/ QL (90 PER 30 DAYS) OXYCONTIN TAB 30MG CR OXYCODONE TIER 6/1/ QL (90 PER 30 DAYS) OXYCONTIN TAB 40MG CR OXYCODONE TIER 6/1/ QL (90 PER 30 DAYS) OXYCONTIN TAB 60MG CR OXYCODONE TIER 6/1/ QL (90 PER 30 DAYS) OXYCONTIN TAB 80MG CR OXYCODONE TIER 6/1/ QL (90 PER 30 DAYS) TRULICITY INJ 0.75/0.5 DULAGLUTIDE ADDITION 6/1/ QL (2 PER 28 DAYS) TRULICITY INJ 1.5/0.5 DULAGLUTIDE ADDITION 6/1/ QL (2 PER 28 DAYS) XIGDUO XR TAB DAPAGLIFLOZIN AND METFORMIN EXTENDED- RELEASE ADDITION 6/1/ XIGDUO XR TAB MG DAPAGLIFLOZIN AND METFORMIN EXTENDED- RELEASE ADDITION 6/1/ XIGDUO XR TAB MG DAPAGLIFLOZIN AND METFORMIN EXTENDED- RELEASE ADDITION 6/1/ XIGDUO XR TAB 5-500MG DAPAGLIFLOZIN AND METFORMIN EXTENDED- RELEASE ADDITION 6/1/ QL = Quanity Limit, 5
6 Covered Drug Name Alternate Drug Name Description of Change Effective Date of Change Tier Utilization Management Notes SELZENTRY TAB 25MG MARAVIROC ADDITION 5/1/ SELZENTRY TAB 75MG MARAVIROC ADDITION 5/1/ APREPITANT CAP 40MG EMEND ADDITION 5/1/ QL (30 PER 30 DAYS), PA APREPITANT CAP 80MG EMEND ADDITION 5/1/ QL (30 PER 30 DAYS), PA APREPITANT CAP 125MG EMEND ADDITION 5/1/ QL (30 PER 30 DAYS), PA RASAGILINE TAB 0.5MG AZILECT TIER REDUCTION 5/1/ RASAGILINE TAB 1MG AZILECT TIER REDUCTION 5/1/ MIRCERA INJ 50MCG METHOXY POLYETHYLENE GLYCOL-EPOETIN BETA ADDITION 5/1/ PA MIRCERA INJ 75MCG METHOXY POLYETHYLENE GLYCOL-EPOETIN BETA ADDITION 5/1/ PA MIRCERA INJ 100MCG METHOXY POLYETHYLENE GLYCOL-EPOETIN BETA ADDITION 5/1/ PA MIRCERA INJ 200MCG METHOXY POLYETHYLENE GLYCOL-EPOETIN BETA ADDITION 5/1/ PA ASA/DIPYRIDA CAP MG AGGRENOX ADDITION 5/1/ QL (60 PER 30 DAYS) AMIFOSTINE INJ 500MG AMIFOSTINE DELETION 4/1/ PA AMIODARONE TAB 100MG PACERONE ADDITION 4/1/ DOXYCYCL HYC INJ 100MG DOXY DELETION 4/1/ PA LOPIN/RITON SOL 80-20/ML KALETRA ADDITION 4/1/ QL (480 PER 30 DAYS) MENOMUNE INJ A/C/Y/W MENINGOCOCCAL POLYSACCHARIDE VACCINE DELETION 4/1/ NECON TAB 1/35 ETHINYL ESTRADIOL AND NORETHINDRONE DELETION 4/1/ MOP CAP 10MG METHOXSALEN DELETION 3/1/ PA ABACA/LAMIVU TAB EPZICOM ADDITION 3/1/ QL (30 PER 30 DAYS) QL = Quanity Limit, 6
7 Covered Drug Name Alternate Drug Name Description of Change Effective Date of Change Tier Utilization Management Notes A-HYDROCORT INJ 100MG CORTEF DELETION 3/1/ PA BUPROBAN TAB 150MG BUPROPION DELETION 3/1/ QL (90 PER 30 DAYS) CERVARIX INJ HUMAN PAPILLOMAVIRUS (HPV) BIVALENT(TYPES 16,18) RECMB VAC DELETION 3/1/ DOCEFREZ INJ 20MG DOCETAXEL DELETION 3/1/ PA ERGOMAR SUB 2MG ERGOTAMINE DELETION 3/1/ EZETIMIBE TAB 10MG ZETIA ADDITION 3/1/ QL (30 PER 30 DAYS) GENGRAF CAP 50MG NEORAL ADDITION 3/1/ PA HUMALOG INJ 100/ML INSULIN LISPRO ADDITION 3/1/ QL (30 PER 30 DAYS), (90) HUMALOG INJ 100/ML INSULIN LISPRO TIER REDUCTION 3/1/ QL (30 PER 30 DAYS), (90) HUMALOG KWIK INJ 100/ML INSULIN LISPRO ADDITION 3/1/ QL (30 PER 30 DAYS), (90) TIER KLOR-CON M20 TAB 20MEQ ER MICRO-K/KLOR-CON/K-TAB REDUCTION 3/1/ (90) KYPROLIS SOL 30MG CARFILZOMB ADDITION 3/1/ PA KYPROLIS SOL 60MG CARFILZOMB ADDITION 3/1/ PA LANTUS INJ SOLOSTAR INSULIN GLARGINE ADDITION 3/1/ QL (30 PER 30 DAYS) LARTRUVO INJ 10MG/ML OLARATUMAB ADDITION 3/1/ PA MENEST TAB 2.5MG ESTERIFIED ESTROGENS DELETION 3/1/ METHOTREXATE INJ 25MG/ML METHOTREXATE ADDITION 3/1/ PA NAPHAZOLINE SOL 0.1% OP NAPHAZOLINE DELETION 3/1/ NIFEDICAL XL TAB 30MG PROCARDIA XL, ADALAT CC DELETION 3/1/ NIFEDICAL XL TAB 60MG PROCARDIA XL, ADALAT CC DELETION 3/1/ NILUTAMIDE TAB 150MG NILANDRON ADDITION 3/1/ QL (30 PER 30 DAYS) RANITIDINE INJ 150/6ML ZANTAC DELETION 3/1/ PA RASAGILINE TAB 0.5MG AZILECT ADDITION 3/1/ RASAGILINE TAB 1MG AZILECT ADDITION 3/1/ QL = Quanity Limit, 7
8 Covered Drug Name Alternate Drug Name Description of Change Effective Date of Change Tier Utilization Management Notes ROSUVASTATIN TAB 10MG CRESTOR ADDITION 3/1/ QL (30 PER 30 DAYS), (90) ROSUVASTATIN TAB 20MG CRESTOR ADDITION 3/1/ QL (30 PER 30 DAYS), (90) ROSUVASTATIN TAB 40MG CRESTOR ADDITION 3/1/ QL (30 PER 30 DAYS), (90) ROSUVASTATIN TAB 5MG CRESTOR ADDITION 3/1/ QL (30 PER 30 DAYS), (90) RUBRACA TAB 200MG RUCAPARIB ADDITION 3/1/ PA RUBRACA TAB 300MG RUCAPARIB ADDITION 3/1/ PA STAVUDINE SOL 1MG/ML ZERIT DELETION 3/1/ QL (2400 PER 30 DAYS) TRAVOPROST DRO 0.004% TRAVATAN DELETION 3/1/ TYZEKA TAB 600MG TELBIVUDINE DELETION 3/1/ PA VITEKTA TAB 150MG ELVITEGRAVIR DELETION 3/1/ QL (30 PER 30 DAYS) VITEKTA TAB 85MG ELVITEGRAVIR DELETION 3/1/ QL (30 PER 30 DAYS) XIIDRA DRO 5% LIFITEGRAST ADDITION 3/1/ QL (60 PER 30 DAYS) YONDELIS INJ 1MG TRABECTEDIN ADDITION 3/1/ PA ZERIT SOL 1MG/ML STAVUDINE ADDITION 3/1/ QL (2400 PER 30 DAYS) QL = Quanity Limit, 8
9 Covered Drug Name Alternate Drug Name Description of Change Effective Date of Change Tier Utilization Management Notes QL = Quanity Limit, 9
10 QL = Quanity Limit, 10
11 QL = Quanity Limit, 11
12 QL = Quanity Limit, 12
13 QL = Quanity Limit, 13
14 QL = Quanity Limit, 14
15 QL = Quanity Limit, 15
16 QL = Quanity Limit, 16
17 QL = Quanity Limit, 17
18 QL = Quanity Limit, 18
Medicare Part D 2017 Formulary Changes OC Preferred
Medicare Part D 2017 Formulary Changes OC Preferred Inter Valley Health Plan may add or remove drugs from our formulary during the year. If we remove a drug from our formulary, add prior authorization,
Medicare Part D 2017 Formulary Changes Service To Senior
Medicare Part D 2017 Formulary s Service To Senior Inter Valley Health Plan may add or remove drugs from our formulary during the year. If we remove a drug from our formulary, add prior authorization,
Medicare Part D 2017 Formulary Changes OC Preferred
Medicare Part D 017 Formulary s OC Preferred Inter Valley Health Plan may add or remove drugs from our formulary during the year. If we remove a drug from our formulary, add prior authorization, quantity
Medicare Part D 2017 Formulary Changes OC Preferred
Medicare Part D 2017 Formulary s OC Preferred Inter Valley Health Plan may add or remove drugs from our formulary during the year. If we remove a drug from our formulary, add prior authorization, quantity
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2018 Drug List Negative Changes Updated 10/25/2018 The table below shows changes made to our 2018 List of Covered Drugs (Formulary).
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You ll find the most up-to-date comprehensive version of our formulary on our website, Click on Drug Finder.
3/1/2018 Medicare Part D Formulary Change In an effort to cover the most needed, cost-effective prescriptions, the AlohaCare Advantage Plus (HMO SNP) Formulary is updated monthly. The following are drugs
During non-business hours, your call will be answered by our automated phone system. A representative will return your call the next business day.
MEICARE AVANTAGE BlueCross BlueShield of Western New York 2018 Formulary Update BlueCross BlueShield of Western New York has updated its formulary (drug list) since its original publication in January
Subject: HPN/SHL COMMERCIAL PDL UPDATES EFFECTIVE JANUARY 1, 2018
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Health Partners Medicare Prime and Value (2017) Updates
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
DIABETES (1 of 5) Generic. Generic $0 $5 $5-10 $0 $0 $0. Generic $0 $5 $5-10. Generic. Generic $0 $5 $5-10 $0 $0 $0. Generic $0 $5 $5-10 $0 $0 $0
Metformin DIABETES (1 of 5) Glucophage Glucophage XR ER $7 (500mg) $7 (500mg) $5 $5 500mg, 750mg only 500mg, 750mg only Sulfonylurea/Combinations Amaryl Glucotrol glimepiride glipizide $5 $5 Glucotrol
Quarterly pharmacy formulary change notice
Provider Bulletin April 2018 This table is used by HealthKeepers, Inc. to indicate formulary changes applicable to all Anthem HealthKeepers Plus members. These changes were reviewed and approved at the
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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Drug Name Description of Change Formulary Coverage Formulary Alternative(s)
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PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES Select Formulary April 1, 2018 Updates. Formulary Alternatives
PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES Select April 1, 2018 Updates Drug Name adapalene-benzoyl-peroxide Gel 0.1-2.5% (Brand = Epiduo ) prasugrel hcl (Brand = Effient ) vigabatrin pak 500 mg (Brand
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DPP4 INHIBITORS Janumet 50 mg-1,000 mg tablet Januvia 50 mg tablet Janumet 50 mg-500 mg tablet Onglyza 2.5 mg tablet Januvia 100 mg tablet Onglyza 5 mg tablet Januvia 25 mg tablet Tradjenta 5 mg tablet
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DPP4 INHIBITORS. Products Affected Step 2: Janumet 50 mg-1,000 mg tablet Janumet 50 mg-500 mg tablet Januvia 100 mg tablet Januvia 25 mg tablet
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Quarterly pharmacy formulary change notice
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August 2016 Formulary Updates
August 2016 Formulary Updates DOXYCYCLINE HYCLATE TABS DR 50MG, 200MG NALOXONE HCL INJ 0.4MG/ML VANCOMYCIN HCL INJ 500MG, 750MG BRIVIACT INJ - PA BRIVIACT ORAL SOLN - QL; PA BRIVIACT TABS - QL; PA LENVIMA
UP Health System Marquette Medication Guideline High Alert Drugs
1 ALTEPLASE SOLR 100 MG ACTIVASE 305010 50242008527 TRUE ALTEPLASE SOLR 50 MG ACTIVASE 305008 50242004413 TRUE AMIODARONE INJ 50 MG/ML CORDARONE IV 305035 63323061609 TRUE AMIODARONE INJ 50 MG/ML CORDARONE
Updates to your prescription benefits
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Health Partners Medicare Prime and Value (2017) Updates
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
Blue Cross and Blue Shield of Minnesota GenRx Formulary Updates
Blue Cross and Blue Shield of Minnesota GenRx Formulary Updates July 2018 TRADE NAME (generic name) or generic name ADVAIR DISKUS (fluticasone-salmeterol aer powder ba 100-50 mcg/dose) Brand Addition ADVAIR
Alprazolam 0.25mg, 0.5mg, 1mg tablets
Presbyterian Senior Care (HMO) / Presbyterian MediCare PPO Quantity Limits Effective November 1, 2014 For the most recent list of drugs or other questions, please contact the Presbyterian Customer Service
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2019 Formulary Update
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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
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
Added, Removed or Changed. Date of Change. No Change
One mission: you s September 7, 2017 Blue Cross of Idaho reviews its formularies (covered drug lists) periodically to allow members access to new drugs and to provide safe, cost effective options for your
2018 Formulary Update
MEDICARE ADVANTAGE BlueShield of Northeastern New York Formulary Update BlueShield of Northeastern New York has updated its formulary (drug list) since its original publication in January. This document
CRITERIA Trial of two generic formulary products from the following: atomoxetine or ADHD stimulant medication.
ADHD STIMULANTS ATOMOXETINE HCL, DEXEDRINE 10 MG TABLET, DEXEDRINE 5 MG TABLET, DEXMETHYLPHENIDATE HCL, DEXMETHYLPHENIDATE HCL ER, DEXTROAMPHETAMINE 10 MG TAB, DEXTROAMPHETAMINE 5 MG TAB, DEXTROAMPHETAMINE
TN Cover Rx Tennessee CoverRx MAC Price Change List As of: 04/26/2018
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